Search found 51 matches

by brownlee47
Thu May 07, 2015 3:05 pm
Forum: Medical Auditing Forum
Topic: 92004
Replies: 1
Views: 2561

92004

When 92004 is used do you have to have a comprehensive HPI and a comprehensive Exam? the CPT states require documentation of a history, but in May AAPC business monthly (pg 39) the example state you have to have a comprehensive HPI
by brownlee47
Tue May 05, 2015 4:28 am
Forum: Medical Auditing Forum
Topic: new problem with work up
Replies: 5
Views: 7000

Re: new problem with work up

I understand that the referral is part of MDM, but what category does the referral fall into?
by brownlee47
Mon May 04, 2015 5:00 am
Forum: Weekly Tip Comments & Discussions
Topic: ICD-10 CHALLENGE Convert the following diagnosis and ICD-9 C
Replies: 2
Views: 3604

Re: ICD-10 CHALLENGE Convert the following diagnosis and ICD

Yes, J45.902, the documentation does not indicate the temporal parameters or severity, which led me to unspecified asthma, with status asthmaticus.
by brownlee47
Fri May 01, 2015 1:22 pm
Forum: Medical Auditing Forum
Topic: 94664 and 94640
Replies: 3
Views: 3926

Re: 94664 and 94640

do you need an order documented or is the nurse documentation indicating she provided the instructions and demonstrated the use good enough to support billing the 94664?
by brownlee47
Thu Apr 23, 2015 10:47 am
Forum: Medical Auditing Forum
Topic: 94664 and 94640
Replies: 3
Views: 3926

94664 and 94640

Can you tell me what need to be documented in order to bill 94664 and 94640. I know they are bundled and would need mod 59, but not clear if there has to be an order if done by the nurse. would the following documentation be appropriate? Child was not very cooperative with treatment, screaming and p...
by brownlee47
Fri Apr 17, 2015 1:25 pm
Forum: Weekly Tip Comments & Discussions
Topic: ICD-10 Challenge Chemotherapy for April 17, 2015
Replies: 2
Views: 2531

Re: ICD-10 Challenge Chemotherapy for April 17, 2015

The appropriate Z51 is the principal dx code, the malignancy for which the therapy is being administered should be assigned as the secondary dx.
by brownlee47
Wed Apr 08, 2015 12:34 pm
Forum: Medical Auditing Forum
Topic: New to Specialty, No HPI
Replies: 2
Views: 2704

Re: New to Specialty, No HPI

Thank you!!
by brownlee47
Fri Apr 03, 2015 12:50 pm
Forum: Medical Auditing Forum
Topic: New to Specialty, No HPI
Replies: 2
Views: 2704

New to Specialty, No HPI

Documentation indicates patient is new to specialty, however provider did not document a HPI: What can I bill? Provider billed 99201 Reason for Appointment 1. Specialist - Urology History of Present Illness General: Nursing Med Review Are you taking any OTCs, herbals or supplements?, No. Current Med...
by brownlee47
Fri Apr 03, 2015 8:24 am
Forum: Medical Auditing Forum
Topic: v58.69
Replies: 3
Views: 3535

v58.69

We are in the process of having an external audit, and the auditor keeps indicating that the documentation for v58.69 is not documented. What needs to be documented in the note to support the code?
by brownlee47
Tue Mar 10, 2015 8:27 am
Forum: Medical Auditing Forum
Topic: 93000
Replies: 3
Views: 3859

Re: 93000

If the provider only documents in the progress note, what the EKG strip machine print out , should we bill only 93005?