Hey everyone, I had a rather interesting webinar that was provided by Humana regarding Medicare AWV’s and in the webinar the presenter states that Z0000 and Z0001 should’nt be used, and threw me off, and I was wanting to know everyones thought’s on this, is right or wronge?
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Tag Archives: conundrum
Documentation conundrum
I have a question that I hope I can get assistance with.
As I go through a patients progress note the physician will say something like "patient needs B12 injection". It is not documented that the patient actually received the injection in the progress note. When I look in another part of the EHR to see if there is an order for the B12 and it is notated that the patient received it, is that documentation in the separate part of the EHR good enough to add the charge for the B12 or should I send a query and request for the information to be added to the progress note.
I know the statement ‘if it’s not documented it wasn’t done’ but how does that pertain when it is documented somewhere else. I’ve also seen this situation with immunizations, supplies that are given and certain procedures.
Thanks for the help
Actinic Keratosis Conundrum
I may be going down the rabbit hole
its late in the day and I might be overthinking, but here goes
A provider is documentation actinic keratosis and ICD guidelines state that a source is needed. This source is not documented. He has also coded 17000 as well as 17003. Past medical history states no personal history of skin cancer, which may very well be.
I maintain that these are to be coded as lesion and the removal of benign lesions should be used unless there is further evidence in the documentation to prove otherwise.
Please opine. I am new to the derm world, be gentle.