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  1. Pathos

    Wiki Risk Adjustment

    I agree with Pam on both conditions. For pure coding purposes, the hypertension is receiving treatment (the T in MEAT, which you will learn more about in Risk Adjustment) with medication. The melanoma appears to be excised and removed, thus no longer considered active or current, which would...
  2. Pathos

    Wiki Vent Dependence

    It might seem like a basic question, but when it comes to coding, the rub is always in the chart note. Our organization always looks at ventilator dependency as only applicable if the provider documents it such. The chart must state ventilator dependency in order to apply this code, and is...
  3. Pathos

    Wiki Category II Code Question

    For Risk Adjustment purposes, 3078F-3077F serves no purpose in code validation as they are not ICD-10 codes.
  4. Pathos

    Wiki MEAT requirements with new E&M changes

    Like SKWashington I would also like to see your physician's argument reference basis. However, MEAT and E&M guidelines are not the same. They may overlap a little or even look similar, but we as HCC coders do not pick up codes based on E&M rules and guidelines. Unless there is a Coding Clinic or...
  5. Pathos

    Wiki Risk Adjustment and Telehealth visits

    Thanks for you reply! Do you have good reference to share on this?
  6. Pathos

    Wiki Morbid obesity coding

    Yup you got it! This Coding Clinic echoes what you and Siddharthaqa said:
  7. Pathos

    Wiki HCC's Risk adjustment reviews

    I have worked from home since March 2020, when the COVID restrictions really hit. Feel free to ask me any specific questions (or private message me).
  8. Pathos

    Wiki Urothelial cancer

    Agreed, in order to help you out more we would need more information of the urothelial cancer, including metastatic status (spread or non-spread).
  9. Pathos

    Wiki DM with HTN

    At the end of the day, the decision to pick up/not to pick up an HCC lies within your organization. Yes, we should follow the guidelines set forth by the ICD-10 book, along with the Coding Clinics, however there are so many gray areas (some done on purpose). I would caution to lean too much into...
  10. Pathos

    Wiki DM with HTN

    UPDATED: I agree with @thomas7331 on this one, and To help explain the "with" and causal link I got this nifty reference to explain a little further: Since DM and HTN are not specifically called out in the Index of any ICD-10 book I have seen, I would recommend we exercise caution when trying...
  11. Pathos

    Wiki Chronic Condition Coding in the ED

    In order to pick up HCC conditions, we need documentation to validate any HCC codes as active conditions. While we have the mostly clear-cut guidelines on how to pick up certain conditions, we have plenty of areas where things get a little more problematic. As @TThivierge mentions, we have the 9...
  12. Pathos

    Wiki MEAT to support DM complications

    I listened to an AAPC Risk Adjustment webinar once, and one of the take-aways was "How high of a risk your organization is willing to take". Yes, we definitely need to follow the rules and guidelines, but when it comes to the more gray areas we are kinda left to our own devices and logic. From...
  13. Pathos

    Wiki MEAT to support DM complications

    Agreed, you can link the labs to both DM2 w/ CKD and neuropathy. The labs are the MEAT in this instance.
  14. Pathos

    Wiki Diabetes 1 and Diabetes 2

    I agree with Thomas on this one. The Excludes 1 notes prohibit us from coding both E10 and E11. However, I would personally go with the code that is best supported if both conditions have MEAT documented. Is this a combined DM1 and DM2 (LADA) or DM 1.5? If the latter, then documentation must be...
  15. Pathos

    Wiki Capturing codes from Physical Exam with no MEAT or support

    You can code from anywhere in the chart as long as there is MEAT to be found. I consistently find MEAT in the HPI, Exam and some cases even in the infamous Problem List and Past Medical History. However, you need to be careful with the last two. Depending on how the chart was documented can make...
  16. Pathos

    Wiki Loss of credentials???

    I would call AAPC today and try to get some kind of agreement going. At the end of the day, AAPC does not want to lose its members, so they might offer you a grace or another chance. At worst they could just say no, but I think it's worth a try to call them.
  17. Pathos

    Wiki E/M training

    In order for me to give suggestions and help, I will need to know a bit more on their reviewing process, and how your work "tear" your explanations apart. What are their criteria? Do they follow their own audit sheets?
  18. Pathos

    Wiki HCC Code Missed

    Correct, HCC coding and claims denials have nothing to do with each other as they are separate parts of how to handle coding. Most Health Plans who participate in Risk Adjustment allow providers to submit additional HCC codes to the Health Plan through other means. The HCC codes on claims are...
  19. Pathos

    Wiki unfair policy

    Have you tried applying to health plans? We currently had an MD from India on our team, and her clinical knowledge is invaluable for all aspects that we deal with (especially surgery appeals and decision making). Also, if a manager/supervisor is scared that you might "steal" their jobs, then...
  20. Pathos

    Wiki unfair policy

    I have been on these forums for a number of years now, and have seen similar posts by frustrated new-grad CPC-As. When I got my certification, I didn't go to coding school, or take any online courses. Instead I had my coding books. the CPC study guide and the online practice exams. I also had a...
  21. Pathos

    Wiki PLEASE CLARIFY THIS CODING UPDATE FOR E&M

    E/M levels will be based on either MDM or time. Here are some good readings on the topic: CMS 2020 E/M guidelines (with references to 2021 changes) AAPC on 2021 E/M changes AMA on 2021 E/M changes CMS Newsroom declaring 2021 E/M changes (article from Nov 2019) CMS Webinar and materials on...
  22. Pathos

    Wiki Giving Up Coding

    The job hunt is frustrating for sure. Took me a whole year from the time I knew I was done working for a company, to the time I actually started my new job. Way prior to that, I just graduated from college, but nobody wanted me. I finally applied to an entry level as a Patient Registrar at my...
  23. Pathos

    Wiki New patient vs Established

    I agree with Thomas, if the documentation supports a New Patient CPT code, then such a code should be reported. Both the provider and the coder have an ethical responsibility to do so regardless of a payer's billing policy. What you are describing could be viewed as "Downcoding" or "Undercoding"...
  24. Pathos

    Wiki Loss of credentials???

    If you received a message from AAPC, I would call their Customer Service right away and see what they can do for you. I know AAPC does not like to lose their members, so it is likely they would work with you. https://www.aapc.com/contactus.aspx
  25. Pathos

    Wiki Giving Up Coding

    If you do reconsider getting certified again, don't go for the full price. AAPC often offers reduced exam packages and I think right now it's around $399 (until the end of this month). This deal included the exam, online practice tests and an actual study guide (which I am a huge supporter of)...
  26. Pathos

    Wiki Family History Codes

    I agree with Thomas on this one. When determining the MDM, you need to look at the whole documentation in its full context, and not just in the A/P as not all charts are created equal. Additionally, if you are using a point system to determine the MDM, then be careful not to over inflate the...
  27. Pathos

    Wiki New visit or etsablished?

    I agree with Thomas. When a payer looks at a claim to determine New vs. Established, the Tax ID is not as important as the group practice of the provider. For example, if the patient goes and sees his PCP at Internal Medicine Doc , and is then referred out to Doctor Heart from Cardiology Docs...
  28. Pathos

    Wiki Can we code from Visit summary after completion of Signature ?

    I agree with athomas4. When you use documentation to support HCC coding and a condition, there should be no doubt that the condition is active under the MEAT/TAMPER guidelines. I would be very hesitant to use the Clinical Summary/Visit Summary for HCC coding. I would rather focus on the rest of...
  29. Pathos

    Wiki Consult vs Established

    The patient type of visit (Consult/New/Established) depends on a number of factors: 1) If the visit is a consultation, then the provider should include the "Rs" when documenting a consult. AAPC has published a couple articles on this subject: Remember the Three Rs for Payers Accepting Consults...
  30. Pathos

    Wiki New pt. level 3 or 4?

    This is true; you wouldn't normally bill an outpatient E/M code for an inpatient encounter. Code either Consult, Initial Admit or Subsequent Visit for the inpatient visit (or Observation if that is appropriate per documentation) instead. My example above was for outpatient visits in general.
  31. Pathos

    Wiki New pt. level 3 or 4?

    You're welcome! Remember when cross walking a consult code to check the patient status New vs. Established. I've had several Consult patients that ended up being an Established patient due to being seen by that provider or someone from their clinic, but with similar credential.
  32. Pathos

    Wiki New pt. level 3 or 4?

    E/M is a fickle creature at best, but there are some help and guidelines out there to help tame the beast. Because CMS has not given us any quantifiable guidelines, but basing them on medical necessity (qualitative), then the auditing becomes very subjective. Some companies (like AAPC), has...
  33. Pathos

    Wiki Major vs. Minor Surgery question

    I think what nhcoding is referencing is a good rule of thumb to determine the Minor/Major surgery in the Risk Table. Otherwise you are over-complicating on something that is not always black/white.
  34. Pathos

    Wiki Can a certified medical coder find a job with no experience at all??

    Hello Ehab! I agree with the other two posters, getting your foot in the medical coding world without any medical experience will be very difficult. At least in the US job market; you state you are looking for work in UAE, perhaps the job market is different there. However, based on the...
  35. Pathos

    Wiki Per CMS, are we able to capture HCC gaps in TeleHealth (video) visits?

    Yes, I believe so as long as the video has synchronous video stream (like Skype or other live video streaming). Can't be a phone call or asynchronous. Here are the key points from CMS: " Effective for services starting March 6, 2020 and for the duration of the COVID-19 Public Health Emergency...
  36. Pathos

    Wiki Considering high risk based on rule out condition or differential diagnosis

    From the official CMS E/M guidelines: "Risk of Significant Complications, Morbidity, and/or Mortality The risk of significant complications, morbidity, and/or mortality is based on the risks associated with these categories: Presenting problem(s) Diagnostic procedure(s) Possible...
  37. Pathos

    Wiki MDM

    Good morning! Per CMS E/M guidelines: "Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering these factors: The number of possible diagnoses and/or the number of management options that must be...
  38. Pathos

    Wiki The Sad Hunt as a CPC-A

    After I graduated from college, I had a bachelor of science and couldn't get nothing for 6 months. I applied, interviewed, did my "song and dance" but no-one seemed to want me. I didn't have any medical experience. It literally boiled down to the point where if I didn't get a job within next...
  39. Pathos

    Wiki CRC Exam

    I work as a HCC coder at a major health plan, and decided to take my CRC last year. I had the study guide and the practice exams only, and passed comfortably. The very interesting part about AAPC exams is that their exams don't replicate 100% the real world, but get fairly close. I also did...
  40. Pathos

    Wiki MDM data points question

    The MDM portion of any E/M visit is often the most subjective part of the E/M visit, and can be tricky to decode/translate into points. When you state if the above example is enough to count 2 points towards the "Review and summarization of old records", in my mind there should be more...
  41. Pathos

    Wiki 8 Chronic Conditions

    According to 2007 Risk Adjustment Data Training for Medicare Advantage Organizations Participant Guide “Chronic conditions such as, but not limited to, congestive heart failure (CHF), Parkinson’s disease, COPD, and diabetes mellitus are chronic systemic diseases that ordinarily should be coded...
  42. Pathos

    Wiki New Patient help

    By definition, a self referred patient is not referred by any provider because the patient is referring him/herself. As the other two posters explain, there is no provider to enter as a referring provider. I am also curious to know why your provider feels they must put someone in as a referring...
  43. Pathos

    Wiki Need Tips for CEMC Exam

    Try this site: https://www.aapc.com/training/practice-exams.aspx#specialty
  44. Pathos

    Wiki The Sad Hunt as a CPC-A

    I would not go as far as to call your hard work and money spent worthless or wasted. No credentialing company can guarantee a job after certification, and AAPC is not exempt of that either. Even new grad nurses don't automatically have jobs lined up for them. Granted, they don't have to step...
  45. Pathos

    Wiki Job searching in USA

    I have not gone through the whole work visa process, but I know if you are a citizen from another country (or non-permanent US resident) and want to work in the US, you'll need to have your company sponsor you and grant you a work visa. Work visas are usually expensive and takes a while to go...
  46. Pathos

    Wiki Sliding scale insulin use

    I can see the logic of picking up Z79.4, but I would still be cautious in picking up a possible diabetes code if the documentation doesn't explicitly state such. Remember that you should be able to defend every code picked if chosen for an audit or even in court. AAPC is also not always...
  47. Pathos

    Wiki New vs Established

    At my previous job, we had the exact same question. We asked Noridian (our local MAC) on further guidance, and they just recited the 3 year rule. Our take was that after 3 x 365 = 1095 days, then the patient would be considered "New" on the 1096th day, so on the 02.11.2020 as Brittany is saying...
  48. Pathos

    Wiki Day in the life of a HCC Coder

    There are many factors that will contribute and detract to getting your first coding job, but it sounds like from what you are explaining that you are on your way with that job lead. I really do hope that it will work out for you and you can get started on your coding career. I don't mean to be...
  49. Pathos

    Wiki Day in the life of a HCC Coder

    Good morning tslone! Before I get into HCC information, I see that you have passed your CPC, but have not been able to get a job. I am curious to know why you are then seeking to get a CRC? I am assuming you are a CPC-A since you have not yet been hired at a coding job? While additional...
  50. Pathos

    Wiki HCC/RAF

    I recently listened to an AAPC Risk Adjustment webinar about Risk Adjustment, and one of the main points the presenter discussed was "The amount of Risk your practice/company is willing to take". In terms of audits, CMS will treat you differently if you are a practice or if you are a health...
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