patient

  1. V

    Wiki Delivery ICD10 Codes

    How would you code a normal vaginal delivery when the patient had gestational diabetes during the pregnancy?
  2. B

    Wiki concussion diagnosis code

    We have a patient coming in who was seen in the emergency room for a concussion and needs a follow up appointmet to be cleared to go back to playing sports. When the patient comes into the office he has no symptoms. Would you code it with the concussion diagnosis code with a D or would you code...
    • buerklej
    • Thread
    • appointment code concussion follow patient
    • Replies: 1
    • Forum: Pediatrics
  3. C

    Wiki Patient expires during procedure

    I hope someone can help with this. My physician took a patient to the OR for emergent ruptured AAA repair. He opened the patient and placed a clamp on the aorta and the patient expired. Can we bill for reduced services either modifier 52 or 53, or was there not enough of the CPT code 35102...
  4. S

    Wiki Fracture Care

    One of my doctor's saw a patient in the office for a suspected fracture. In his note he diagnosed her with a left supracondylar fracture. He decided to treat this nonoperatively and planned to see the patient back in a week. I charged out fracture care for a closed treatment of a supracondylar...
    • sloseke
    • Thread
    • care fracture patient supracondylar visit
    • Replies: 0
    • Forum: Orthopaedics
  5. J

    Wiki Manipulation of previous fracture and re-casting in the office

    My Ortho billed the global codes for fracture care without manipulation for a patient who had a tib-fib fracture. The patient presented to the office for a follow-up visit with a complaint that the cast was too tight and bothering her. He removed the cast and x-rays show that the fracture site...
    • jdibble
    • Thread
    • bill cast fracture manipulation patient
    • Replies: 2
    • Forum: Orthopaedics
  6. N

    Wiki ER vs Inpatient E&M code

    Hi everyone! Any help would be appreciated!!! Neurosurgeon is on call. He sees the patient in the ER, but, the patient is admitted the same day. Do I code as an inpatient or do I code the ER consult? I was told that only the ER physician can code ER consults. And, per Medicare of VA, you can no...
  7. C

    Wiki H&P billing after patient delivering the baby in the car

    Can the provider bill the H&P on a patient who actually delivered before arriving to the labor and delivery unit ? Followed the delivery the provider saw the patient ... ? Pls help
    • CODING1234
    • Thread
    • delivery h&p labor patient provider
    • Replies: 1
    • Forum: OB/GYN
  8. T

    Wiki new patient help please

    We have a physician that is seeing a patient for the first time from China attending school here. Blue cross ppo. The patient has no problems she only came in to get a Gardasil shot. The doctor spent time with the patient going over problems/history/family history etc. How can this be billed...
  9. W

    Wiki prolonged services question

    When attempting to determine the appropriate E/M codes to use when an extensive amount of time has been spent with the patient (and documented appropriately :) ), how do you figure out the initial E/M code to use? For example, if you have a 90 minute established patient office visit, do you...
    • wbradhoward
    • Thread
    • code e/m patient prolonged services visit
    • Replies: 2
    • Forum: E/M
  10. J

    Wiki Medical Receptionist

    The successful Medical Office Receptionist at Nashville Family Foot Care, PLLC will perform high quality administrative duties in a fast paced medical office setting with a concentrated focus on exceptional patient service. General responsibilities include: • answering multi-line phone system •...
  11. L

    Wiki ICD 10 coding - COPD with emphysema and multifocal

    Patient discharged: COPD with emphysema and multifocal atrial tachycardia. what codes would you use?
  12. M

    Wiki Exam components - constititutional must it be relevant to CC?

    I work for a dermatology office. The physicians usually assess the patient's general appearance- "Patient appears well nourished, developed, stated age and not in apparent distress". For the exam portion under 97 guidelines we count that as "constitutional" bullet. One of our coders went to...
  13. R

    Wiki Removal of Spleen and suture of mesentery

    Can both the removal of the spleen (38100) and suture of the mesentery (44850) be coded??? is a 55-year-old gentleman who underwent pancreaticoduodenectomy (Whipple procedure yesterday 11/05/2015). He initially remained stable, but then developed hypotensive episodes and clinical evidence of...
  14. V

    Wiki Z01.00 vs Z01.01

    I am curious if anyone is having trouble getting Z01.01 processed as a routine visit. For example, patient schedules yearly exam. During exam all findings are normal accept the patient mentions that they occasionally have headaches or dry eye. We are using 92xxx CPT codes and use Z01.01 as the...
  15. M

    Wiki Need help with cpt for VAIN2

    Here is the op note. Provider is billing 57061. PROCEDURES: 1. Wide local excision of vaginal intraepithelial neoplasia 2 (VAIN 2), bilateral fornices. 2. Laser brushing of vaginal mucosa. FINDINGS AT THE TIME OF SURGERY: Atrophic vaginal mucosa. Bilateral fornices areas of acetyl white...
    • monicahkfan
    • Thread
    • bilateral fornices mucosa patient vaginal
    • Replies: 0
    • Forum: OB/GYN
  16. kathymoon

    Wiki Inpatient in the office?

    I am getting back into coding and billing after doing auditing for the last 6+ years. Also, new to ENT billing. Here's one I've never come across before. The patient is admitted for a sublingual abscess. The patient was seen in consult by the ENT in his office (which is attached to the...
  17. L

    Wiki OV by MD & Acupunture in same day

    We recently added an acupuncturist to our practice. I am wondering if we can schedule our patient's for an office visit to see their PCP and also schedule an appointment for the patient to see the acupuncturist on the same day. This is a very common request that our office receives, so...
    • LeaHarris
    • Thread
    • acupuncturist office patient patients schedule
    • Replies: 0
    • Forum: E/M
  18. A

    Wiki Encounter After Surgery

    Neurosurgeon did laminectomy on patient about a year ago. Patient presents for post operative examination. No complications and incision has healed. I cant seem to find anything for encounter of musculoskeletal. Any thoughts?
  19. C

    Wiki Aspiration syndrome

    The patient is an adult and one of the diagnosis is the above. I did a query to the provider as to identify what the patient aspirated on, The provider's response was oral secretions. The patient also had pneumonia as one of the diagnosis listed. I am not sure how to code the aspiration...
  20. S

    Wiki Need Help with ICD-10 CODES

    The patient has developed a stage II pressure ulcer on the sacrum and reports pain from the ulcerated area. Examination reveals that the wound is covered with black eschar and is surrounded by chronic inflammation with dark pigmentation. It is determined that the patient is not a candidate for...
  21. M

    Wiki coder

    My doctor is wanting to use over the medication to make his risk higher and charge a 99214. Eztablished patient and stable problem HTN. No labs or other complexity ordered or reviewed. He feels if he tells the patient to take 3 ibruprofen at a time instead of the usual 2. It should be...
  22. K

    Wiki Advance Care Planning 99497-99498

    Description for these code state when performed "by physician or other qualified healthcare professional." In our situation, physician talks to patient for about 5 minutes and then sends the patient to the social worker who spends another 45 minutes with them filling out forms. Would this be...
  23. D

    Wiki Injections and PA or Dr to be rendering

    If Dr. A sees a patient and does the H&P and X-rays and all of the office visit portion and leaves the room then his credentialed Physician Assistant goes in alone and gives the patient an injection in her knee. Dr A’s documentation is for the OV portion and PA’s documentation is for the...
    • DAV829
    • Thread
    • billed documentation injection patient portion
    • Replies: 1
    • Forum: Orthopaedics
  24. T

    Wiki Smoking and tobacco use cessation

    Is anyone having a problem getting these codes paid 99406 or 99407. We are using dx F17.210 along with whatever problem the patient came if for and with the proper documentation of the provider counseling the patient. We are also adding a 25 modifier on the office visit. Is there something...
  25. M

    Wiki New to ENT. Lots of Questions re: when to bill E/M with a scope

    Hi. I'm new to ENT coding and I have several questions that I hope you can help me with. First when the doctor does a laryngoscopy in the office, how do you count this in the data complexity part of the audit sheet? I'm thinking that he should get a point in the medicine part-- The same line...
  26. C

    Wiki Is the Q0 modifier required for OP Medicaid Patient getting an AICD?

    I am curious if the Q0(zero) modifier is required to be added to CPT 33249 for patient undergoing a OP procedure for implantation of an Automatic Implantable Cardiac Defibrillator primary prevention. I know thi sis required for Medicare. I am unsure is this applies to Medicaid. Any help would...
  27. D

    Wiki 99232 question help

    one of our doctors came into our practice in January and he seen a patient in the hospital for three different days. we are getting a denial that its global pt is in the post op period, we found out that the doctor did surgery on the patient when he was in another practice- not sure how to do...
  28. T

    Wiki injection only to be billed out?

    I don't see anything coming out to be able to bill the E/M with the injection. any thoughts?? I am still trying to understand and learn the E/M. its fairly new to me. 1. Right knee pain. HPI: Appointment type: Established patient - Established problem Patient returns for his right...
    • trose45116
    • Thread
    • examination history injection knee patient
    • Replies: 3
    • Forum: E/M
  29. T

    Wiki Medicaid-Patient's primary

    Patient's primary insurance paid for 99242 consultation except $25 copay. Patient's secondary ins Medicaid denied cpt 99242 as non covered by plan. Can we bill the patient for the $25 or do we have to adjust it off?
  30. T

    Wiki initial or subsequent - injections for the patient

    ok I think I am reading too much into this. I have a patient who comes into the office for MRI results and the doctor is going to order HA injections for the patient. This would still be the (A) for initial because the doctor is still actively treating the patient, right??
    • trose45116
    • Thread
    • actively doctor initial patient treating
    • Replies: 4
    • Forum: ICD-10
  31. C

    Wiki Canceled LHC, coded as Central Line Placement Thoughts?

    I would like you thoughts regarding this op report. the staff have charged/coded this as a central line placement. The patient was brought into lab for a cath, physician canceled cath. A standard 6 French sheath was inserted (no other supply) into femoral vein for IV fluids and dopamine. This...
    • Chlrtrep
    • Thread
    • cath central line patient placement
    • Replies: 2
    • Forum: Cardiology
  32. A

    Wiki Prolonged services

    Hello all, I need more guidance or help into the process of billing for prolonged services along with an E/M office visit. My specialty is a pediatric neurology and my provider spends additional time on reports and such for the patient care on autism patients. Please if there is anybody who...
  33. J

    Wiki I&D Scrotal Abscess

    PROCEDURES IN-OFFICE: SURGEON: Emily White FNP FINDINGS AND PROCEDURE: Patient was placed in a supine position. Patient has a scrotal abscess. The area was prepped and draped. The abscess was incised, purulent material drained, and the cavity was irrigated with sterile water. Incision was...
    • jflynn124
    • Thread
    • abscess incision patient procedure scrotal
    • Replies: 3
    • Forum: Urology
  34. T

    Wiki Presenting Problem & Management Options

    If a patient has more than 4 diagnoses or the patient is on dilaudid or any type of monitoring would that make it a high complexity decision making? If there is a reference to this I would greatly appreciate the help. Thank you.
    • TMB1965
    • Thread
    • complexity decision greatly patient reference
    • Replies: 0
    • Forum: E/M
  35. O

    Wiki Needing Help Coding Office Visit!!!

    Our physician saw a patient under observation status in the hospital, and then saw him in the clinic for the first time as a new patient. We billed the hospital consult with an e/m office visit code, saw him in the office and did surgery the following day. We used a modifier 57 on this visit...
    • Orthocoder269
    • Thread
    • hospital modifier office patient visit
    • Replies: 0
    • Forum: E/M
  36. M

    Wiki 92226 & Wasitng of J0585 (Botox)

    Atena is the only one not paying this code. Any suggestion how can I billed this code so I can start getting paid? Most of the time they pay only on the New Pt. Otherwise they deny it saying "Experimental". My Second Question is if a patient do not show up for Migraine treatment and the meds...
  37. N

    Wiki lmft seeing medicare patient

    Does any one have feedback on how to go about the following situation... A severe chronic patient has changed insurance and now has medicare. i know that LMFT can not bill medicare. The patient is in no way stable enough to change providers. is there a way to handle this? the patient is willing...
  38. D

    Wiki Coding for screening exam

    I work for an ophthalmologist and I have a patient who presented for "routine" exam, but has family history of glaucoma. (VISIT WAS JULY 2015 SO ICD-9!) Patient has enlarged cup to disc ratio and as such is considered "glaucoma suspect". What is the best way to code this exam so that Aetna will...
  39. M

    Wiki modifier 24 - I have a biller

    I have a biller who says a 24 modifier is appropriate on a claim and I question the validity. Looking for validation for the following scenario: Patient had several procedures in June 2015, only 1 of which has a 90 day global, CPT 46930 Destruction internal hemorrhoid. In early Sept 2015, still...
    • melaapc04
    • Thread
    • global surgery modifier modifier 24 note patient
    • Replies: 3
    • Forum: Modifiers
  40. J

    Wiki J3301 - associated tenderness

    Hello everyone- Im just wondering some input on how you would code this? My main concern is the kenalog. I currently bill at a neurology clinic and me & the other biller do not agree on how to code the J3301. Would love to hear what my fellow members think? Thank-You in advance =) Procedures...
  41. N

    Wiki ICD 10 Doubt

    Hi sir I have one doubt in ICD 10 Patient came to the hospital for heel wound , patient had multiple surgery on heel. Final diagnosis documented as surgical Chronic left heel wound- healing with no signs of active infection Please sir, write ICD 10 code this scenerio
  42. S

    Wiki Standing Orders

    I have a situation where a practice has nurses see patients under standing orders for immunizations, TB tests, and some labs. They want to bill these services under the chief of staff NPI number (due to the standing orders). The situation, I feel has gotten out of hand. Nurses may triage a...
  43. T

    Wiki can we bill an office visit with the injection??

    Chief Complaints: 1. Bilateral hip. HPI: Appointment type: Established patient - Established problem Patient returns for the MRI results of both hips. She denies any other complaints . ROS: Unchanged from 12/16/2015. Medical History: Infection, headaches...
    • trose45116
    • Thread
    • hip history left pain patient
    • Replies: 1
    • Forum: E/M
  44. T

    Wiki can we charge office visit with the injection???

    can we charge the office visit with the injection?? please any help appreciated. Chief Complaints: 1. Bilateral hip. HPI: Appointment type: Established patient - Established problem Patient returns for the MRI results of both hips. She denies any other complaints ...
  45. S

    Wiki Hardware removal after fracture

    Just verifying one more time! If patient is having hardware from ORIF removed, I'm just going to use Z47.2 and no fracture code, right? Patient is not having complications or pain. Thanks!
  46. N

    Wiki Need Help Concussion Coding

    Need some guidance on concussion coding, patient comes in with concussion without loss of consciousness still having problems with headaches and fatigue referred by family physician, our provider coded S06.0X0S, I don't agree I think it needs to be coded F07.81 then S06.0X0A initial encounter...
  47. C

    Wiki Vaginal Delivery at 21 weeks nonviable.. diagnosis code

    I need assistance choosing the correct diagnosis. I would appreciate if you guys can help. patient was admitted for having abdominal pain, her diagnosis was preterm labor, the next day patient had vaginal bleeding, membranes were noted in the vaginal vault. tocolysis was initiated a. due to...
    • CODING1234
    • Thread
    • delivery diagnosis nonviable patient vaginal
    • Replies: 0
    • Forum: OB/GYN
  48. 1

    Wiki Preop HP billing

    If a surgeon in a group schedules a patient for a major surgery, but sends the patient to their PCP for the HP, what is the correct way of billing both services? The global package includes payment for some pre op work. So if PCP in another group does HP, what is the correct way to bill?
  49. J

    Wiki Hospital Discharge date-of-service

    A provider does a discharge summary on one day and the patient is not really discharged until the following day, which DOS do we use for the discharge? If we use the DOS for the real discharge day but the discharge summary has the day before’s date on it, do we need an addendum in order to bill...
  50. M

    Wiki Inpatient vs observation

    I do the insurance appeals for various hospital facilities, I have gotten the following denial several times regarding patients that are originally authorized and admitted as an inpatient but their stay was extended due to continued need for medical treatment. The denial that I will get states...
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