Search found 32 matches

by bill.wong
Tue Dec 04, 2018 1:57 pm
Forum: Medical Compliance Forum
Topic: Xray Orders and Coding Compliance
Replies: 1
Views: 864

Re: Xray Orders and Coding Compliance

Hi Gibbons, The guidance we would give in Compliance is two folds: 1. Seek clarification from provider by having them update the note to reflect the radiograph report or the other way around...which ever is accurate...through an addendum. If that is not possible, 2. I would only code the facility co...
by bill.wong
Thu Jul 05, 2018 12:11 pm
Forum: Medical Auditing Forum
Topic: Assistant Surgeon Documentation Requirements
Replies: 2
Views: 576

Re: Assistant Surgeon Documentation Requirements

This is from Palmetto GBA: What type of documentation is needed to support an assistant surgeon's claim? Answer: After additional review, Palmetto GBA has modified guidance regarding documentation requirements for assistant at surgery or surgical assistant (billed with HCPCS modifier AS and CPT modi...
by bill.wong
Fri Sep 08, 2017 1:03 pm
Forum: Medical Auditing Forum
Topic: Exam: Nail bed discoloration
Replies: 1
Views: 765

Re: Exam: Nail bed discoloration

Being a former clinician myself, I would say "No." Discoloration of nail bed can also be due to other factors such as blunt trauma (i.e, Subungual Hematoma) or infection. Therefore, a coder cannot make that clinical judgement.
by bill.wong
Tue Aug 29, 2017 1:41 pm
Forum: Medical Auditing Forum
Topic: Venipuncture documentation requirements
Replies: 1
Views: 824

Re: Venipuncture documentation requirements

Yes. If you can get that out of your nursing staff, that is a blessing. At one of my previously employment, we were lucky to get "Labs drawn" which was suffice for us. Ideally, like any other procedure or service, I would like to see as much as the following as I can (some may not apply): • Procedur...
by bill.wong
Tue Aug 29, 2017 1:34 pm
Forum: Medical Auditing Forum
Topic: New or Established PROBLEM w/no tx after 2 years
Replies: 1
Views: 609

Re: New or Established PROBLEM w/no tx after 2 years

I cannot find resources that explicitly state one side or the other, so this is my opinion. I believe that this patient's condition should be considered established. Unless it can be confirmed that the condition resolved, only to reappear, I would not code this as a new problem. I do not think any a...
by bill.wong
Tue Aug 29, 2017 1:16 pm
Forum: Medical Auditing Forum
Topic: Medical Decision Making elements
Replies: 1
Views: 841

Re: Medical Decision Making elements

Unfortunately, that is the nature of the the beast. You can have a patient with a new insignificant problem such as sniffles, with Medication management, that could support Moderate MDM. Conversely, you have a returning cancer patient that has not improved, as you mentioned, with high acuity that wo...
by bill.wong
Tue Aug 08, 2017 11:05 pm
Forum: Medical Auditing Forum
Topic: CRC Credential
Replies: 1
Views: 648

Re: CRC Credential

I have a colleague in my Coding & Compliance Team that has it. She does not use it at all. I have another friend that got it a few years ago and it opened up a job opportunity with Humana RA Role which pays her about $20K more than her previous position. I can see Managed Care and Risk Base Coding b...
by bill.wong
Fri Aug 04, 2017 11:37 pm
Forum: Medical Auditing Forum
Topic: Physical Examination Elements
Replies: 1
Views: 687

Re: Physical Examination Elements

I would give the provider a comprehensive exam. Here is my breakdown: 1. Skin - left-sided small scalp laceration 2. Constitutional - Neck is in a collar 3. Respiratory - Scattered rhonchi 4. CV - Tachycardic, normal rhythm 5. GI - Abdomen: Soft and tender 6. MS - He has abrasions, no obvious deform...
by bill.wong
Fri Aug 04, 2017 11:26 pm
Forum: Medical Auditing Forum
Topic: Intubated patient
Replies: 1
Views: 616

Re: Intubated patient

Hi Shoshana, For me to give the provider credit for a comprehensive history, I would need to see this documented: 1. Provider couldn't get history from patient due to altered mental status, intubation, etc 2. Provider ATTEMPTS to get history from another source such as family, friends, EMT, etc 3. D...
by bill.wong
Fri Aug 04, 2017 9:41 am
Forum: Medical Auditing Forum
Topic: HPI Elements
Replies: 1
Views: 654

Re: HPI Elements

Hi Mary, It really depends if your Medicare carrier allows you to use a pertinent negative for Associate Signs/Symptoms. I would use "Denies numbness/tingling" for Associated Signs/Symptoms as long as you have not used it to get Neuro for your ROS. I am sure you know this, but you cannot use the sam...