Search found 7 matches

by saj402
Thu May 14, 2015 12:30 pm
Forum: Medical Auditing Forum
Topic: DX coding from Indication on radiology report
Replies: 1
Views: 1879

DX coding from Indication on radiology report

Hi, I am struggling to find an answer/source for this scenerio. In the ED a patient will have an xray or CT done and the indication listed at the top of the report will be "pain". A chart that I was recently reviewing pt had a CT of C-spine for "pain" (per the Indication on the report). However, in ...
by saj402
Fri Apr 10, 2015 10:34 am
Forum: Weekly Tip Comments & Discussions
Topic: Weekly tip 69210 - instrumentation
Replies: 2
Views: 2762

Weekly tip 69210 - instrumentation

I am struggling with this a little bit as CPT Assistant defines "instrumentation" as the use of an otoscope and other instruments. I find my providers do not document the use of an otoscope. Does the documentation of the procedure require they say the use an otoscope to get credit? Oct 2013 CPT Assi...
by saj402
Fri Mar 20, 2015 9:31 am
Forum: Weekly Tip Comments & Discussions
Topic: ICD-10 Challenge - Critical Care
Replies: 5
Views: 3808

ICD-10 Challenge - Critical Care

Dx T63.452, toxic effect of venom, could better support Critical Care services. R68.89, other general symptoms is pretty vague.
by saj402
Wed Feb 11, 2015 2:21 pm
Forum: Weekly Tip Comments & Discussions
Topic: Weekly Tip-Scoring MDM ER Encounter
Replies: 5
Views: 5459

Re: Weekly Tip-Scoring MDM ER Encounter

Thank you for your explanation. However, may I add that the ED is a different setting than an office visit. In the Emergency Department, because of the readily availability of comprehensive diagnositc testing, assessments are frequently shortened to a single E/M encounter, with the work-up performed...
by saj402
Fri Feb 06, 2015 10:10 am
Forum: Weekly Tip Comments & Discussions
Topic: Weekly Tip-Scoring MDM ER Encounter
Replies: 5
Views: 5459

Weekly Tip-Scoring MDM ER Encounter

Hello, I am confused that this is not considered "with workup". The pt had labs and an EKG during the encounter. Isn't the patient being "worked up". Also under the management options pt had IV fluids so would that be considered Low?

And thank you for providing these scenarios!
by saj402
Wed Oct 08, 2014 9:10 am
Forum: Medical Auditing Forum
Topic: Coding conditions from PMH
Replies: 4
Views: 4108

Coding conditions from PMH

Hello, I audit outpatient Emergency and Observation records. I am in a constant struggle with coders and clients on assigning conditions from the PMH. An example I have is a patient that presents to the ED with an ankle injury after falling. Pt has a PMH of hypertension and DM and is on Lisinopril a...
by saj402
Fri May 16, 2014 1:21 pm
Forum: Medical Auditing Forum
Topic: Table of risk OTC vs Pres drug mgmt
Replies: 2
Views: 3251

Table of risk OTC vs Pres drug mgmt

Hello, In the table of risk under Management Options we are running into some confusion on where to place a patient that receives an OTC medication (such as ibuprofen, Motrin, tylenol) during an Emergency Room visit. Patients come into the Emergency Room for a headache, ankle sprain, or fever and th...