Laureen shows you her proprietary “Bubbling and Highlighting Technique”
Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page
We are trying to determine if we are allowed to bill separately for the administration of medications prior to and after a procedure such as a laceration repair or a wrist reduction done in the ER. Often after a wrist reduction in the ER the patient will receive Zofran for nausea and Dilaudid for pain control. Any insights would be greatly appreciated.
In my example this is what I have – Hx is Detailed, Ex is Detailed…clear and cut…But the MDM I think I am overthinking and I need some assistance or tutoring…In the assessment I usually have 4 dx codes, sometimes more…For this example I have dx codes listed G89.4 (Chronic Pain Syndrome), M54.12, (Radiculopathy cervical region) M25.511 (rt shoulder pain), and M25.512 (lt shoulder pain)—-Provider states Reviewed UDT, MRI, and Refilled Rx Opioids
Do I count- 4 points dx under the dx/management options because he has 4 dx listed (High)…….2 points for Data (UDT and MRI review) LOW, and under Risk- MODERATE for Rx refill and he states in the Risk section 1 chronic condition with mild exac- this leads me to believe it’s the Chronic Pain syndrome since he is managing the patients pain
I am thinking Moderate Overall—-High on dx/managment, Low on Data, and Moderate on Risk….Am I doing this right…..the dx are all established codes…no indication of worsening,
Thanks
Willie
Please keep in mind that these are Medicare/Medicaid patients if that makes a difference.
__________________________________________________ __________________________________________________ ____________________________________________
For established outpatient office visits, the documentation only requires TWO out of THREE of the required level of History, Exam and Medical Decision Making.
This being the case, if you have a note that contains a Comprehensive History, Comprehensive Exam, and Low Complexity MDM would that not be completely billable as a 99215? There is a divide between people wanting to bill based on the documentation and the information provided, and people wanting to bill based solely on the Medical Decision Making who would bill the above as a 99213.
If anyone has any information that could help swing this disagreement one way or the other, it would be greatly appreciated.
Thank you.
I need a second or even a third opinion on this. I am auditing a note, and under the HPI the only documentation is as follows:
Chief complaint – This 65 year old female presents for hypertension.
History of Present Illness – "Hypertension – risk factors include age over 60 and obesity. Additional information: follow up"
What, if any, elements of the HPI would you credit for this documentation?
thanks!