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  1. M

    Wiki SOAP note for E&M Service

    FTessa Bartels- I agree this is poor documentation and normally my supervisor have us take it back to the provider and have them to rewrite or add to the note. Ofcourse they are bothered and upset by it but I tell them it's this way or I code a lower level or its doesn't get billed. (I work for...
  2. M

    Wiki Retail Health Clinic and MDM selection: advice needed

    You actually may not be missing anything. Just reread what the doctor says about the bronchitis. Look to see what he states is the pt's symptoms. And if that's still not helping you come to the conclussion that the risk is moderate, u can also use HTN cause that's a chronic illness and I'm sure...
  3. M

    Wiki Retail Health Clinic and MDM selection: advice needed

    HTN is a chronic condition alone so that's a moderate risk level and also if acute bronchitis is new problem then that's all the proof you will need to support the 99214.
  4. M

    Wiki Retail Health Clinic and MDM selection: advice needed

    In my opinion the exam can be either expanded or detailed depending on your auditing tool and with acute bronchitis being moderate risk, I can see why you would code this visit a 99214.
  5. M

    Wiki Doubledipping ROS and Exam

    Basically, if the doctor document something in the ROS and not the EXAM, its considered double dipping if you try to use it in any other area. If the doctor notate similiar info in both areas, it's not considered double dipping.
  6. M

    Wiki Albuterol - I have an account that I'm

    The "golden rule" we as coders have to live by is "Not Documented, not done". How can you bill somebody if there is no documentation or proof that the patient actually took it? Are they breaking the law by actually charging pt's for meds if they actually don't see the pt taking it? Hope my...
  7. M

    Wiki auditing question

    It all depends on the auditor as to the number of audits per hour. To give a specific number will be hard to do considering not all the providers have the same legible handwriting nor do they document the same. Just provide an estimate number that's not too high as they will be looking for you...
  8. M

    Wiki Doubledipping ROS and Exam

    I was taught that you can't double dip. This was something my co-workers was questioning aswell. But we were told by a compliance auditor that double dipping is not allowed since HPI/ROS, Exam and MDM are considered seperate parts of a visit.
  9. M

    Wiki Medical Decision Making - self limited problem

    I agree, Dr's need to be a little more specific with URI's. With the auditing tool a RX automatically makes the MDM moderate complexity but I was taught that if the HPI/ROS and Exam is not detailed then it's not a 99214. You probably can get away with a 99213 just to be on the safe side of not...
  10. M

    Wiki Need icd9 please

    Yes it applies. In my book under 607.1 it states Balanoposthitis. The foreskin is called prepuce and if you look under infection-prepuce, it gives 607.1 (hope this helps)
  11. M

    Wiki Coding without a delivery note

    I was always told if there is no documentation then the visit never happened. Dr's make mistakes all the time, how are we to know that they did their SB's correctly if there is no documentation to back it up. I look at it this way, if I'm audited and there is no documentation to back up my...
  12. M

    Wiki H1N1 coding

    With medicaid I was told to use 90470 with V04.81 and with medicare and third pary payors use G9141 with V04.81 I currently work for a health dept and this is what we have to do. We are also having issues with what to code for H1N1 but this was the latest info I've received. Hope this helps
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