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

Practice Exam

CPC Practice Exam and Study Guide Package

Practice Exam

What makes a good CPC Practice Exam? Questions and Answers with Full Rationale

CPC Exam Review Video

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Practice Exam

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

Practice Exam

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

Accounting for Time in Documentation

Are inaccuracies in patients’ medical records costing your practice? Accurate documentation of time in the medical record serves two purposes: to ensure quality patient care and to meet requirements for reimbursement. A detailed statement concerning time spent with a patient is a critical component in the accuracy and efficacy of their medical record. When the […]

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AAPC Knowledge Center

Meet Documentation Requirements for Psychotherapy Services

Here’s what the OIG is looking for, and Medicare carriers will be too. Did healthcare providers meet Medicare requirements and guidance when billing for psychotherapy services during the public health emergency (PHE) for COVID-19? The Office of Inspector General (OIG) conducted a nationwide audit to find out, and recently published their findings. It is not […]

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AAPC Knowledge Center

Clean Up E/M Documentation With SOAP

The old standby still works like a charm to show medical necessity. The American Medical Association’s (AMA’s) 2021 Evaluation and Management Services Guidelines (2021 E/M guidelines) are the biggest change in medical coding since the creation of the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services by the Centers for Medicare & Medicaid […]

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AAPC Knowledge Center

Q&A: Coding from ED documentation and test results

Q: Can you code strictly from emergency department (ED) documentation? Can you code from test results and imaging (radiologist reports)?
 
A: Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ED physicians or other providers (nurse practitioners and physician assistants) can be used to assign a code.
 
This comes with two notes of caution, however. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ED physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.
 
As for the second piece of your question, diagnosis codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnosis codes, as such physicians do not provide direct patient care. Coders or clinical documentation improvement (CDI) specialists would need to query the attending provider to assign the appropriate diagnosis code.
 
Coding Clinic for ICD-10-CM/PCS has published guidance regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.
 
Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and CDI education specialist at HCPro, a division of BLR, in Danvers, Massachusetts, answered this question on the ACDIS website. Contact her at [email protected].
 
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

 

Need expert coding advice? Submit your question to editor Steven Andrews at [email protected] and we’ll do our best to get an answer for you.

HCPro.com – JustCoding News: Inpatient

Assistant at Surgery Modifiers Require Specific Documentation


Over my almost 30-year surgical coding career, the documentation for assistant surgeons consisted of only the name of the assistant surgeon in the operative note header. Most often there was no mention of the role of the assistant surgeon in the body of the operative note; it was assumed the assistant surgeon provided an extra set of hands to execute the surgery. That used to be enough for payers, but not anymore.

Payers Want More Info:

Payers no longer consider the assistant surgeon’s name in the header only as sufficient documentation. They want the body of the operative note to indicate what the assistant surgeon contributed to the surgery. They also want documentation in the operative report to explain why an assistant surgeon was used at a teaching institution rather than a qualified resident.

Support Modifier 82:

An “assistant at surgery” is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The “assistant at surgery” provides more than just ancillary services. 

The fact sheet states, “Documentation must include information relating to the unavailability of a qualified resident in this situation.”

This means you cannot assume there wasn’t a qualified resident available. To support modifier 82, the operative note should state,
  • why there was no qualified resident available; and
  • why a non-resident assistant had to assist with the surgery.

When coding or auditing surgeries performed at a teaching facility, make sure this information is included in the body of the operative note.

The operative note should clearly document the assistant surgeon’s role during the operative session.”

This means that the mention of an assistant surgeon only in the operative note header is not enough to support coding for and billing for an assistant surgeon’s services. 

The operative not needs to include what the assistant surgeon contributed to the surgery in the body of the operative note.

Assistant at Surgery indicators:

  • 0 = Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity
  • 1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at Surgery may not be paid
  • 2 = Payment restrictions for assistants at surgery does not apply to this procedure. Assistant at Surgery may be paid


Coding Ahead

E/M Documentation for Teaching Docs Changes July 1, 2019


There is a change in Medicare policy forthcoming regarding evaluation and management (E/M) services documentation requirements for teaching physicians.

It is important to train teaching physicians, residents, and nurses who document E/M services of all changes to be implemented on July 1, 2019.

For purposes of payment, E/M services billed by teaching physicians require that the medical records must demonstrate,

1) That the teaching physician performed the service or was physically present during the key or critical portions of the service when performed by the resident;

2) The participation of the teaching physician in the management of the patient.

The patient medical record must document the extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary. The extent of the teaching physician’s participation may be demonstrated by the notes made by the notes in the medical records made by physicians, residents, or nurses.

What Is CMS Telling Us?

The teaching physician’s participation may be documented by either the teaching physician, resident, or nurse as of July 1, 2019. This is a loosening of the current requirements, as we now may only use the teaching physician’s documentation of the participation. Documentation by the resident or the nurse of the teaching physician participation currently does not count in current documentation. But as of July 1, 2019, the resident’s and nurse’s documentation of the teaching physician’s participation will be counted.

Current attestations may not be used, as they do not include the “extent of the teaching physician’s participation in the review and direction of the services furnished to each beneficiary.” This means that current attestations will need to be extended to include free text that is specific to the beneficiary encounter, which will be different for each beneficiary.

For more Details: Click Here


Coding Ahead

Assistant at Surgery Modifiers Require Specific Documentation

Over my almost 30-year surgical coding career, the documentation for assistant surgeons consisted of only the name of the assistant surgeon in the operative note header. Most often there was no mention of the role of the assistant surgeon in the body of the operative note; it was assumed the assistant surgeon provided an extra […]

The post Assistant at Surgery Modifiers Require Specific Documentation appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

28 DME Documentation Checklists

If you want to smooth reimbursement claims for durable medical equipment, CGS offers 28 documentation checklists that identify what must be included. Recently updated, these checklists include the following items and services: Enteral nutrition Glucose monitors and supplies Hospital beds and accessories Immunosuppressive drugs Large volume nebulizers and inhalation drugs Lower limb prostheses Manual wheelchairs […]

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AAPC Knowledge Center

Inpatient Admission Documentation Requirements

I have a physician stating that the documentation does not require a remark stating the patient was admitted. (IE: I am admitting John Doe today due to his high blood pressure) My understanding that this should be included in the documentation but I am unable to find any guidelines stating so. Looking for any information available for guidance.

Thank you :)

Medical Billing and Coding Forum

Inpatient Admission Documentation Requirements

I have a physician stating that the documentation does not require a remark stating the patient was admitted. (IE: I am admitting John Doe today due to his high blood pressure) My understanding that this should be included in the documentation but I am unable to find any guidelines stating so. Looking for any information available for guidance.

Thank you :)

Medical Billing and Coding Forum