Coding Challenge

Counseling Must Dominate Exception Claims For Seamless Payment

Choose the service level using the documented history, exam, and MDM. Question: A new patient with a chronic gastric ulcer meets the gastroenterologist for management of her condition. The gastroenterologist meets for 34 minutes with the patient, and performs an expanded problem focused history and exam and straightforward medical decision making. The note also indicate that [...] Related articles:

  1. E/M Challenge: Can I Report 99214 and +99354?Counseling representing more than 50 percent of E/M visit? Choose...
  2. E/M Coding: Don’t Sell Yourself Short on Problem Sports ExamsTip: Time-based E/M might be in line when managing diabetes,...
  3. How Do I Code Genetic Counseling By A PhysicianLimit 96040 to Trained Counselor Question: May we report 96040...

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February 25, 2010
Coder's Cranium

Set the Record Straight: ICD Code Options for COPD

What your pulmonologist writes in the documentation matters. The pulmonologist’s documentation, along with the patient’s medical record can make or break your chronic obstructive pulmonary disease (COPD) reporting. One key is making sure that your coding accurately identifies the patient’s specific pulmonary condition and any other associated acute condition (if necessary). Background: According to the National Heart [...] Related articles:

  1. 3 Pulmonary Diagnosis Coding TipsRemember to focus on acute conditions & exacerbations. Correctly reporting...
  2. How Do You Code COPD With Acute Bronchitis?  Question: An established patient with chronic obstructive pulmonary disorder (COPD)...
  3. Should You Code Presenting Symptoms Along With Dx? Question: An established patient complains of trouble breathing and...

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February 25, 2010
CMS / E/M / Hot Coding Topics

Get Paid for EM Visits: How Much ROS Documentation Is Enough?

Caution: Keep enough paperwork on hand to back up EHR. Transitioning to the world of Electronic Health Records (EHR) can make your coding easier on many levels, but don’t take it for granted. Physicians often fall short in their review of systems (ROS) documentation whether you use paper charts or rely on EHR, but you can [...] Related articles:

  1. Bullet-Proof Level-4, Level-5 E/Ms with These ROS Documentation TipsROS documentation musts that most practices get wrong. Gastroenterology Coders:...
  2. E/M Coding Focus: Geriatric Patients & DementiaDetermine HPI or ROS during assessment for geriatric patients. Your...
  3. Bulletproof Your Doc’s PSA Documentation with This Form You’re just one click away from a code-focused order....

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February 25, 2010