Click here for more sample CPC practice exam questions with Full Rationale Answers

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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

Dermatology- Is this area considered the LIPS or the FACE?

Hello,
Looking for clarification on this location please.
When coding dx and procedures on the area of skin directly under the nose, not touching the actual lip or lip border at all, is this still considered the "upper lip" or "other part of face?"
I know code choices will differ depending on what location this falls under.

Thank you in advance for your response.

Medical Billing and Coding Forum

Assistant Surgeon claim denial: considered inclusive …

In GYN surgery, the primary surgeon did multiple procedures. The assistant surgeon assisted with only one of those procedures. The procedure that had the assistant was considered inclusive of the other services done by the primary surgeon. Does the assistant surgeon have any standing for appeal? I have no administration over the claims or billing of the primary surgeon. The assistant surgeon is reaching out to me to see if there is anything he can do to get paid.

Medical Billing and Coding Forum

E.R. E/M HPI for Sickle Cell-Is Acute Exacerbation Considered ‘Chronic Condition’ ?

Hello, I am auditing emergency room claims and I noticed that another auditor had made a determination for an acute exacerbation of sickle cell HPI to be a single chronic condition and this brought the rating down to an EPF for the history component, which brought the ER visit down to a 99283.

Somehow, it didn’t seem right to label an acute exacerbation of a chronic condition as just a chronic condition.
To me, somehow that is like labeling a hyperglycemic incident as a chronic condition of diabetes?

Any thoughts?

Medical Billing and Coding Forum

What is considered an implant? Please respond

HI All this may be a silly question but physician wants to bill for implant removal of the ankle 20680, he did a ligament repair with OrthoCord. Pt is now having issues with this and Doc when back to remove or debride the orthocord This is how the note reads. The skin and soft tissues were carefully dissected avoiding any neurovascular structures. The suture knots where the OrthoCord was placed in the lateral ligament complex were easily identified as they were prominent and had an abundant hypertrophic scar tissue around them. All encountered suture knots were sharply debrided and removed. So my question is would OrthoCord be considered an implant? I don’t believe so but before I go to the physician I would like other opinions.

Medical Billing and Coding Forum

Are these considered central line placements?

1) R femoral vein introducer placed.

2) Placement of a dual lumen temporary R femoral hemodialysis catheter placed.

Is a central line placement, CPT 36556, appropriate for these procedures referenced above?

In order to report a central line placement, MUST the provider state where the tip resides? Many times I do not see any documentation indicating where the tip of the device terminates. I see that ultrasound is used quite a bit to locate the vein, but no doc indicating where the tip of the catheter terminates.

Please help!

Medical Billing and Coding Forum

96102 – Who is considered “technician”?

We are a teaching facility. Psychological Testing* was administered by a Psychology Student.

Later on, a Psychologist (PsyD,HSPP) reviewed and interpreted and prepared a report which began like this – "The following is the psychological report from the above psychological testing. I personally spent over 2 hours supervising and interpreting this assessment and report…."

This obviously cannot be 96101, since the Psychologist did not perform the testing and cannot be coded for interpretation and report of 96102 & 96103.

Is 96102 appropriate here with the Psychology Student as "technician"? or would this be an unbillable service?

96102 – Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI and WAIS), with qualified health care professional interpretation and report, administered by technician, per hour of technician time, face to face.

*Tests Administered:
Minnesota Multiphasic Personality Inventory-Restructured Form (MMPI-2-RF)
Millon Clinical Multiaxial Inventory-III (MCMI-III)
Measure of Symptom Validity
Thematic Apperception Test

Thank you in advance.

Diane

Medical Billing and Coding Forum

Aspects Considered In Electronic Medical Record

Even if electronic medical records systems wit computerized provider order entry, or CPOE, have existed for more than thirty years, less than ten percent of all hospitals in the United States, as of the year 2006, have fully incorporated electronic medical records into their systems.

In the year 2008, about thirty eight percent of office-based physicians accounted fully or partially using electronic medical records systems for their work processes. However, the same research found that only roughly twenty percent of all physicians reported using a system depicted as functional in minimal value and engaging in orders for prescriptions and examinations, viewing laboratory or imaging results, and clinical notes.

Electronic medical records, like their paper-based counterparts, must be kept in unaltered state and authenticated be their creators. Under data encryption and protection regulations, responsibility for patient records and documents, disregarding the forms they are kept in, is always on the creator and the custodian of the documents.

The tangible medical records are the property of the medical provider or institution that sets them up. This involves films and tracings from diagnostic imaging procedures, such as x-ray, CT scans, PET, MRI imaging, ultrasound, and other. The patient, however, has the right to have access at the original documents of electronic medical records, and obtain copies under law.

Most national and international sets of standards accept the use of electronic signatures. Applicable to electronic medical records, an electronic signature authenticates a digital scribe by indentifying the signer with the signed file or document. When the signer creates a mark in a unique manner, that becomes can be attributed to the signer.

Using electronic medical records in reading or editing a patients records or documents is not only possible through a health care workstation, but it depends on the type of machine and health care settings. It may also be possible through using mobile devices that are capable of understanding and translating human handwriting. Electronic medical records can include ease of access to personal health records, which makes individual notes from electronic medical records readily available for patients who needs the records for documentation.

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Related Medical Coding Articles

Can a hospital stay be considered “outpatient” if more than 4 days

We had a patient who was initially under 23 observation stay but the case management in the hospital couldn’t get it approved for inpatient stay. She is a patient with severe comorbidities and complications. She had to stay in the hospital for 5 nights before discharge. Since hospital classified it as outpatient we have no choice but to bill 99211-99214 codes. However, our biller said that Blue Cross Medicare Advantage will deny the claims since we cannot bill outpatient codes consecutively for more than 3 days. I had called the hospital and they maintain that it is an outpatient stay.

What is the ruling for this situation and how do we go about billing it?
We have the medical records to prove service is rendered however, the technicality of outpatient stay of more than the 2 midnight rule is confusing.

Thanks.

Medical Billing and Coding Forum