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  1. K

    Wiki Do they Count- orders only referenced

    If a provider determines that the patient needs to be assessed by a specialist, orders medications, imaging or lab work... but the orders for these is not actually captured in the note as legit orders- does this still count? I know the orders can technically be seen in the medical record, but...
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    Wiki clearance for respite care admittance

    Good Morning- I have been wracking my brain trying to figure out the appropriate way to code a visit that was for an evaluation prior to admittance to a respite facility. The provider discussed all of the patients history with the family and then added all of the conditions the facility should...
  3. K

    Wiki MA providing Scribe and MA duties

    I have a question from a compliance stand point regarding the use of a medical assistant as a scribe. I understand that an MA can be used as a scribe, but my question is regarding the use of the MA as a scribe AND MA during the same visit. Meaning- the MA checks the patient in, does the regular...
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    Wiki Telemedicine Originating Site Billing Q3014

    If our facility is billing for being the originating site for a telemedicine visit, what would you suggest the ICD-10 would be for this charge? Would you want to use the diagnosis associated with the visit that the billing provider would use at the distant site? Or maybe something more along the...
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    Wiki To bill or not to bill: missing documentation question

    This is probably going to sound like a pretty obvious question, but I am really starting to struggle with this after discussions with my coworkers on code assignment. When I was first starting out as a coder, I was taught that when documentation points for a procedure are missing from a note...
  6. K

    Wiki New patient or established after COVID19

    With the directive that any patient, new or established, coming into the clinic to be swabbed for COVID19 should be billed with a 99211 when the test is done in clinic, how does that affect the coding/billing of any subsequent visit in the clinic. Is the patient considered established now or is...
  7. K

    Wiki How to handle confirmation sample collections

    Good Afternoon, I work for a clinic that has done a few confirmation tests on patients who have tested positive for COVID-19. But they are also doing second collections for confirmation the next day. Example: Patient comes in 7/1 to be tested due to symptoms. We bill a 99211 for the nurse...
  8. K

    Wiki Pre-senile cataract removal in adult patient

    Good Afternoon. I am trying to find guidance on how to properly code a pre-senile cataract that was removed for a 21 year old patient. The encounter was for a cataract global transfer of care, and coded as the surgical center coded the procedure. The encounter was billed with the juvenile...
  9. K

    Wiki Intoxicated Patient

    Good Afternoon, I am struggling with the proper coding for the following scenario: with or without intoxication Patient comes in to the clinic intoxicated and is confused about why he is here. He was found in the parking lot confused and inebriated by staff and brought in for immediate...
  10. K

    Wiki Diagnosis missing from assessment but documented in Exam

    I am hoping that someone can help me with an issue I am having. I know that I have found guidance on this type of situation before, but apparently didn't save it for future reference. So any help you can give is greatly appreciated! Q: Can I add a diagnosis code based on findings in the exam...
  11. K

    Wiki Epi Pen Prescription Visit Help

    I am struggling to find guidance on how to properly code a patient encounter for a prescription of an epi-pen. To give a little back ground: PT is coming in before camping to get a RX for an Epi-pen. The PT has never had an anaphylactic experience, only local reaction. Not currently...
  12. K

    Wiki Auditing Experience

    I was wondering if anyone can help me with ways to gain experience in a auditing? I have been googling training's, but what i am really looking for is hands on practice or something to make me get a feel for how it should be done in real life. I am a CPMA, but do not necessarily feel that...
  13. K

    Wiki Chronic Conditions

    I have a question that I am struggling finding solid documentation on, so I am hoping someone on here can point me in the right direction, or at least guide me to a solid answer. If a patient is being seen by my provider for only one of the 4 chronic issues the patient has, even if the provider...
  14. K

    Wiki G0299 Home Health or Hospice code question

    I am looking for some help with billing home health services by RN's. This code does not specify that it is ONLY for Hospice, rather it says it is for Home Health OR Hospice services. We are getting denials that this is only for Hospice and that we can not use it. I have been trying to find...
  15. K

    Wiki Behavioral Health Notes and Addendums

    I am looking for some help with some supporting documentation and or thoughts from other coders that have worked in the behavioral health arena for a while. Since I am new to the behavioral health arena, it is hard to find rules and guidelines for documentation requirements that reference...
  16. K

    Wiki fetal heart tones

    I am looking for help on what would be the correct diagnosis for a patient that an ultrasound was done on due to the mothers weight restricting the ability to hear the fetal heart tones. I do not feel that the diagnosis code of "obesity complicating pregnancy" is the appropriate code. I do not...
  17. K

    Wiki Use of Acronyms in Chart Notes

    Good Afternoon! I am wondering if anyone out there can help me. I work in a clinic that has a unique range of providers, we have A&D Counselors, Mental Health LCSW's, MD's, PA's, ARNP's, Dental and Pharmacy. Because we have such a range of providers, we have many different styles of notes that...
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