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    Wiki Preventive Only Policy

    I have a provider that does not want to bill additional E/M visits with Preventive visits. The AAPC's CPMA study guide says, "When auditing preventive services, it may be the policy of the office to bill for a preventive service only, and not to bill for a problem visit even if one is provided...
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    Wiki E&M Exam no positive findings

    I'm auditing a provider who is documentating the same comprehension exam with negative findings despite the presenting symptoms. Can anyone tell me of a specific guideline that states that the exam must address the positive findings of the chief complaint. My coworkers disagree with my concern...
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    Wiki Documentation Requirements EP study - Non interventional Radiology

    Good morning, Does anyone have any resources/training materials on the documentation requirements of EP study and non interventional radiology? Thanks
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    Wiki What is the Cheif complaint?

    CPT states "A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter, usually stated in the patient I was always taught that even when there an absence of symptoms and the patient is being seen for a...
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    Wiki What is the Cheif complaint?

    Thank you all for responding. I think I agree with @teresabug in this regard. I think this documentation is too unclear...Was it a follow-up of the recent UTI, afib. I would code the a-fib, hx UTI, status AKA, long-term wafarin, but there is no CC.
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    Wiki What is the Cheif complaint?

    I should have mentioned that this is a subsequent Nursing Facility Visit. The dx selected by the physician was 997.60 Amputation Stump Complication NOS My understanding is the principal diagnosis should be the condition that is cheifly responsible for the continued residence. Because he...
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    Wiki What is the Cheif complaint?

    Good morning, I wanted a second opinion about this chart. What would you say is the Cheif Complaint? How would you code this chart? INTERIM HISTORY: This is an 68 year old male with history significant for CAD, DM2, HTN, atrial fibrillation on warfarin, PVD s/p L AKA, vascular dementia, and...
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    Wiki Radiation Oncology-Correct provider

    Good morning, I have a question for all Radiation Oncology Coders. Who is the proper provider for services rendered. Currently we code everything with the Oncologist as the provider, amd I am not sure that is correct. We are a facility. I know certain codes are technical only and some are...
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    Wiki Help with ROS statement

    Gail, That is what I would like to see, and am working on getting all of the dr's on the same page. In the meanwhile, I flip flop as to whether that statement is sufficient. :confused:
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    Wiki Help with ROS statement

    Please review the ROS statement below and let me know if you consider it specific enough to give credit for a complete ROS. A few of my physcians use variations of the all systems reviewed and negative unless in HPI and I am not sure how I feel about it. Thanks CHIEF COMPLAINT: Fever, Short...
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    Wiki Question about MDM in ED

    Good morning, I have a question about scoring MDM in the ED. When you are looking at # of diagnosis treated, how do you score? I know the problem status in 'new' or 'established' to the practitioner. I had a discussion with another coder, because I feel that that a presenting problem is...
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    Wiki Help! Alcohol abuse v. dependence

    I never received a reply. I found the answer myself via Coding Clinic. Hopefully this may help someone else. Coding Of Substance Dependence And Abuse Alcohol Abuse and Alcohol Dependence (Alcoholism) ICD-9-CM makes a distinction between alcohol dependence (category 303) and alcohol abuse...
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    Wiki Help! Alcohol abuse v. dependence

    I have an ER physcian who wants to know the clinical distinction between alcohol use (303) and alcohol abuse (305.0_). The only information I can find is the DSM IV criteria and I don't know if ICD 9 uses the same rational. http://www.ncbi.nlm.nih.gov/books/NBK44358/ Can anyone help? Thanks...
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    Wiki question about UTI dx

    Thanks for your reply. The ICD-9 code for 599.0 states to "use additional code to identify organism". Thats why I asked, because that is not always specified.
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    Wiki question about UTI dx

    Good morning, My physician dx UTI with based on urinalysis. In order to code a UTI, I must also code the bateria. Without a culture, is it appropriate to code 599.0 and 041.9? Also, if there is a culture and the results come back stating "no growth" do I code the symptoms only? Thanks in...
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    Wiki Help with Ecodes

    Thanks. With inversion injuries it is usually a patient stumbling and inverting the ankle, but not falling. Should I just code the activity i.e walking?
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    Wiki Help with Ecodes

    Hello all, Can anyone help with these codes? Which ecode would I use for a patient with an injury from inverting the ankle. It is not a fall so I am not sure if e885.9 is correct. Also I have a patient with a fracture from jumping off a ledge. It also was not a fall. Would I just use E917.9...
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    Wiki Help with fracture care

    I have a patient who came in and has a metatarsal fracture. This is the read of the x-ray. Transverse nondisplaced fracture through the base of 2nd, 3rd and 4th metacarpals are identified. The alignment at the tarsals appears to be maintained. Bony mineralization is appropriate.The dr...
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    Wiki *HELP* with documentation guidelines

    Great, Thanks so much.
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    Wiki *HELP* with documentation guidelines

    Am I correct, that in order to count ROS and PFSH from nurses notes the Dr. needs to a note ststing he has reviewd the nurses notes. If it is an electronic note does that still apply if the Dr. has to close the chart. Would that count as an acknowledgement of review? Thank you
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    Wiki J code denials:modifier 59 on 94640?

    I never bill 94640 with a modifier 59. The E&M visit w/ mod 25 I think is correct.
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    Wiki Splint documentation help

    Hello, I have a pt. who had a splint applied by the radiology tech. There is no order from the dr., however the dr.'s note on the pt. chart states that the splint was applied by the tech under his supervision, and that he was present for all key portions of the procedure and immediately...
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