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2018 CPC Practice Exam Answer Key 150 Questions With Full Rationale (HCPCS, ICD-9-CM, ICD-10, CPT Codes) Click here for more sample CPC practice exam questions with Full Rationale Answers

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Click here for more sample CPC practice exam questions and answers with full rationale

Past, Family, and/or Social History (PFSH)

Have some confusion in understanding the proper way to document a PFSH. I have a provider who only documents " Patient’s medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate " in all his visits

Per E/M guidelines: You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.
You may document the review and update by:
• Describing any new ROS and/or PFSH information or noting there is no change
in the information
• Noting the date and location of the earlier ROS and/or PFSH

by him signing and dating below, is this sufficient to account for a PFSH????

This is an example of the providers documentation:

Chief Complaint
Patient presents with

• Hypertension

*
*
HPI patient is here for htn,. He has been on medication in the past. But has not had insurance. Now he was unable to past a dot physical to drive big rig.
*
Review of Systems
Neurological: Positive for headaches.
*
*
*
Patient’s medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
*
*

Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished.
Cardiovascular: Normal rate.
Neurological: He is alert and oriented to person, place, and time.
*
*
*
Assessment:
*
1. HTN, goal below 140/90 losartan (COZAAR) 50 MG tablet
* DISCONTINUED: losartan (COZAAR) 50 MG tablet
*
RTc in 1 week for bp control.

Electronically signed by XXXXX, DO at 10/23/2017 *9:40 AM

Medical Billing and Coding Forum

How to Document E/M with Counseling and/or Coordinating Care

The only case when time may be used as the overriding factor in determining an evaluation and management (E/M) level is when counseling and/or coordinating care dominates the encounter, which means that the time expended on counseling and/or coordinating care exceeds 50 percent of the total encounter time. This applies to non-time-controlled E/M services that […]
AAPC Knowledge Center

MDM- “Amount and/or Complexity of Data Reviewed”

I am in need of some advice on some records I’m reviewing. This is directly related to the "Amount and/or Complexity of Data Reviewed" of the MDM component.

If the Physician notes she performs a "Urine Toxicology Screening", checking for RX compliance, and mentions she personally "reviewed the dipstick herself which provides a preliminary result for the potential of more or more drugs", how many points does this qualify for?

One total, for the review and/or order of clinical labs?
Two total, for the independent visualization of a specimen?
Three total, for ordering/reviewing and also independent visualization?

I’ve seen many conversations about this, but no hard documentation that says truly which one. I’ve researched in Optum’s Evaluation and Management Coding Advisor and it isn’t answered for my scenario. I’ve Googled and can only find opinions, but nothing from bigger reputable sources. If anyone has something in writing I would greatly appreciate it!

Thanks so much!

Medical Billing and Coding Forum

Modifier 25 and/or 57

I bill for a plastic surgeon that is called by the ER department regularly. He presents to the ER and does a consult and at times it leads to an emergency surgery. My problem is that we are continually denied the consult reimbursement. After appeal, with documentation, we are still denied. This has been happening mainly by United HC. Does anyone have any experience with this issue?

Thank you

Medical Billing and Coding Forum

Endometriosis and/or adenomyosis sufficient pathology to upcode

Hi All!
During our CPT coding meeting, the question was brought up that if a uterus was submitted for uterine prolapse and endometriosis alone or with adenomyosis were found, would this be significant enough pathology to warrant an upcode to an 88307? Any thoughts?

Medical Billing and Coding Forum