Search found 43 matches

by JJones
Thu Sep 26, 2019 12:28 pm
Forum: Medical Auditing Forum
Topic: Laparotomy vs. Open procedure
Replies: 0
Views: 27

Laparotomy vs. Open procedure

Hello! Thank you in advance for any guidance you can give us on this subject. We see these type of notes frequently, and want to be sure we are coding correctly. [/ From a recent chart note: b] "The 2 specimen retrieval bags were grasped trough the camera port. The pneumoperitoneum was evacuated and...
by JJones
Thu Aug 15, 2019 3:31 pm
Forum: Medical Auditing Forum
Topic: External Cause Codes for Injuries
Replies: 0
Views: 2361

External Cause Codes for Injuries

Hello! Thank you in advance for any guidance you can offer. On a recent internal audit, it was observed that some coding staff in the trauma specialty are not using external codes while coding procedures for the initial treatment. For example abdominal wound repairs due to assault by a gun, or heart...
by JJones
Fri Apr 05, 2019 9:46 am
Forum: Medical Auditing Forum
Topic: Pediatric/Neonate E/M coding
Replies: 0
Views: 1646

Pediatric/Neonate E/M coding

Hello! We recently began coding for pediatrics, both in-patient and out-patient. We have a question regarding the History portion, specifically the ROS as to what would be acceptable documentation for the neonate patient. Would it be sufficient if the provider added a note stating something to the e...
by JJones
Thu Mar 21, 2019 10:58 am
Forum: Medical Auditing Forum
Topic: Groin Sheath and Impella procedure
Replies: 0
Views: 1584

Groin Sheath and Impella procedure

Hello! Thank you in advance for any help. We are trying to determine what is the correct CPT code(s) for this case copied below. The physician feels it should be the artery repair because this is not the usual way of removing the sheath. CCI shows 33992 (removal of impella) as major procedure with t...
by JJones
Thu Feb 07, 2019 1:43 pm
Forum: Medical Auditing Forum
Topic: Replacement Assistant at Delivery
Replies: 0
Views: 586

Replacement Assistant at Delivery

Hello! Thank you in advance for any help you can give us on this unusual scenario. During the course of a recent C-section Delivery (after failed trial of labor), an assistant was used who also is a MD but not with our practice. Prior to the end of the procedure, she was called to another delivery. ...
by JJones
Thu Oct 18, 2018 1:38 pm
Forum: Medical Auditing Forum
Topic: Dexamethasone Sodium Phosphate
Replies: 1
Views: 650

Dexamethasone Sodium Phosphate

Hello! We are wondering if anyone else is having trouble when billing for this drug. The administration routes for J1110 state IM, IV, OTH. We are presuming the "OTH" means oral. We have been having issues with our providers dropping a J8540 as it says oral, but charges are denied as this form is a ...
by JJones
Thu Oct 18, 2018 12:15 pm
Forum: Medical Auditing Forum
Topic: Prolonged Services - Inpatient
Replies: 0
Views: 518

Prolonged Services - Inpatient

Hello! Thank you in advance for any help provided with this question, and I apologize for the length of this de-identified note. We are trying to determine the levels that are billable. The provider billed as a 99223, 99356 and a 99358. We (Coders) are only seeing a 99223 and a 99358 being met: DATE...
by JJones
Mon Oct 08, 2018 9:02 am
Forum: Medical Auditing Forum
Topic: Student catches baby during delivery
Replies: 1
Views: 674

Student catches baby during delivery

Hello!

We have a questions regarding correct billing involving a student in training who caught the baby at delivery. The provider was present the whole time as a preceptor. We are not a resident teaching facility. Are we still able to bill for the delivery service?

Thank you so much!

J Jones
by JJones
Tue Aug 21, 2018 4:30 pm
Forum: Medical Auditing Forum
Topic: Data Points for ordering imaging for NG tube placement
Replies: 1
Views: 722

Data Points for ordering imaging for NG tube placement

Hello!

Thank you in advance for any help for this medical decision making question.

One of our coders is wondering if a data point for ordering imaging to confirm placement of a NG tube would be correct?

Thank you,

J Jones
by JJones
Tue Jul 10, 2018 1:40 pm
Forum: Medical Auditing Forum
Topic: Prolonged Care 99356
Replies: 1
Views: 550

Prolonged Care 99356

Hello! In the past we have been dinged with errors from outside auditors for allowing conversations with physicians and phone calls with patient family towards prolonged care code (99356). The reason stated only face-to-face can count towards prolonged care. Unit floor time would be for the base cod...