Search found 432 matches

by admin
Thu Jan 17, 2019 9:21 am
Forum: Medical Auditing Forum
Topic: 3 chronic or inactive conditions
Replies: 1
Views: 15

Re: 3 chronic or inactive conditions

Hello, HPI is part of the subjective part of the visit. How sick is the patient according to the patient? The information to support the status of three chronic conditions would be the provider documenting the responses of the patient about how they are being effected by the presenting problems. Lab...
by admin
Wed Jan 16, 2019 11:52 am
Forum: Medical Auditing Forum
Topic: HIV Template-help
Replies: 1
Views: 19

Re: HIV Template-help

Hello, Below are the HPI elements we can credit in this information. HIV Patient has been having no symptoms Possible medication side effects include none. No side effects from current meds. The patient has disclosed HIV status to parent(s), other Overall quality of life is unable to work, but able ...
by admin
Wed Jan 16, 2019 11:48 am
Forum: Medical Auditing Forum
Topic: New Dermatology Biopsy Codes and Modifiers
Replies: 1
Views: 16

Re: New Dermatology Biopsy Codes and Modifiers

Hello, I have included slides from the CPT Changes 2019 Webinar presented by NAMAS that may help clarify the use of the new biopsy codes. All the information in the slides comes directly from the 2019 CPT code book. There are a lot more instructions in this area of the book that are not in the slide...
by admin
Thu Oct 25, 2018 9:40 am
Forum: Medical Auditing Forum
Topic: Dexamethasone Sodium Phosphate
Replies: 1
Views: 328

Re: Dexamethasone Sodium Phosphate

J8540 Dexamethasone, oral, .25 mg “The corticosteroid dexamethasone works in the body to control inflammation. One unit of this code represents 0.25 mg of dexamethasone. The route of administration is oral, which is given through the mouth.” “Brand names for this drug include: Baycadron Elixer, Deca...
by admin
Thu Oct 18, 2018 12:19 pm
Forum: Medical Auditing Forum
Topic: Endocrinology HPI and Exam
Replies: 4
Views: 494

Re: Endocrinology HPI and Exam

Hello,

It is true, but in this particular case, if you use the 1995 guidelines, you can use the stools for AS&S for the fat malabsorption.

J Paul Spencer
by admin
Wed Oct 17, 2018 10:54 am
Forum: Medical Auditing Forum
Topic: Endocrinology HPI and Exam
Replies: 4
Views: 494

Re: Endocrinology HPI and Exam

Without a clear date and time, the vitals documented in the second half of the question below can’t be credited. If there is a date and time, this counts as a Constitutional system under 1995 guidelines, or as one bullet under 1997. For 1997, this would qualify as the status of three chronic conditi...
by admin
Wed Oct 17, 2018 10:07 am
Forum: Medical Auditing Forum
Topic: Student catches baby during delivery
Replies: 1
Views: 341

Re: Student catches baby during delivery

Usually in the delivery room, the physician is in attendance, but a delivery nurse does the bulk of the work. As long as the physician is in the room, and upon delivery, works with the maternity team to stabilize the newborn postpartum, the delivery charge can be billed. Who caught the baby doesn’t ...
by admin
Wed Oct 10, 2018 9:29 am
Forum: Medical Auditing Forum
Topic: Auditing CAPD
Replies: 2
Views: 396

Re: Auditing CAPD

Good morning, I am most positive that we have not dealt with that specific service. I would encourage you to research any CPT Assistant article that might provide insight into the code specific guidance. However, please note that the code you mentioned is an unlisted procedure code and while they sh...
by admin
Mon Oct 08, 2018 8:08 am
Forum: Medical Auditing Forum
Topic: Co-surgeon 2 specialty requirement
Replies: 1
Views: 453

Re: Co-surgeon 2 specialty requirement

Good morning, It is possible some payers will not follow the guidance from CMS, but my experience with the major ones is they do. You will have to search your individual payer policies to know for sure. This may be as simple as a quick google search. For example, I googled BCBS co surgeon and the fi...
by admin
Thu Oct 04, 2018 1:59 pm
Forum: Medical Auditing Forum
Topic: Minimal sedation with E/M service
Replies: 1
Views: 276

Re: Minimal sedation with E/M service

Minimal sedation is included in the E/M services as it is done using medication, that does not require extensive independent monitoring, or injection services. Since it is not a separately billable service, and does not require independent monitoring, it does not have to be excluded when documentati...