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Tag Archives: documented

Death of the Documented History, Rise of the Patient Advocate

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When clinical documentation gets overrun with auto-populated data, it’s time to redirect technology to better serve our patients. Medical providers will no longer be required to document the history/medical interview during outpatient/office services in health records starting Jan. 1, 2021, per the 2019 Medicare Physician Fee Schedule (MPFS) final rule. This new policy is supported […]

The post Death of the Documented History, Rise of the Patient Advocate appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Restarted Infusion Without Documented Stop BEforehand

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Hello All,

I’m hoping to get some opinions regarding how to handle an unusual documented infusion entry. The patient received an infusion of lactated ringers, with frequency documented as Continuous. The times are documented as follows:

3/19 1117 New Bag 100mL/hr
3/19 1338 New Bag 100mL/hr
3/19 1444 Rate/Dose Verify 100mL/hr
3/19 2051 New Bag 100mL/hr
3/20 0028 Rate/Dose Verify 100mL/hr
3/20 0343 Restarted 100mL/hr
3/20 0613 Canceled Entry 100mL/hr
3/20 0614 Stopped 0mL/hr
3/20 0628 New Bag 100mL/hr

Normally, since this was documented as a continuous frequency infusion, I would count from the first entry on 3/19 1117 through 3/20 at 0614; However, with the "Restarted" entry and no "Stopped" time before that, I think I can only charge from the Restarted Time of 3/20 0343 through the Stopped Time 3/20 0614. The other question we had was whether the documented infusion time prior to the "Restarted" entry can be coded at all, mainly as IV pushes as opposed to infusion.

I appreciate any suggestions you may have :)

Tracy

Medical Billing and Coding Forum

PCPs & CPT Cat II codes for documented Eye Care

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Hello Coders,

Can a primary care physician, i.e., family practice, submit the following CPT Cat II codes to close HEDIS gaps in care if they receive an eye exam report for their diabetic patients (from an eye care professional), review the report and place it in the patients’ medical record?

2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed
2024F: 7 standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed
2026F: Eye imaging validated to match diagnosis from 7 standard field stereoscopic photo results documented and reviewed
3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)

Thanks for reviewing this!

Yvette Peak

Medical Billing and Coding Forum

Coding Signs and Symptoms not documented in the Assessment portion of Exam

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Hi ,

I know you probably see this question a lot. My scenario is a patient is possibly schizophrenia. The rheumatologist provider does not establish medical necessity to support patient is schizophrenia. Provider mentions that patient has memory loss in both the HPI and exam. Is is acceptable for me to report memory loss in conjunction to schizophrenia? Can you please put valid sources?

Medical Billing and Coding Forum

Diagnosis on signed order and not documented in provider notes

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When looking for medical necessity for ancillary services performed during an ED or observation encounter, if the attending provider signs his order with a medically necessary diagnosis and fails to document accordingly in the record, is it safe to assign that diagnosis to cover? Are there any Medicare guidelines I may be able to refer to about this?

Medical Billing and Coding Forum

ROS negative except as documented in HPI question

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I would appreciate any thoughts on this as there isn’t agreement in my office. Would this be acceptable documentation for a 10pt ROS?

Thank you?

Review of Systems Constitutional: Negative except as documented in history of present illness.
Eye: Negative.
Ear/Nose/Mouth/Throat: Negative.
Respiratory: Negative except as documented in history of present illness.
Cardiovascular: Negative except as documented in history of present illness.
Gastrointestinal: Negative.
Genitourinary: Negative.
Musculoskeletal: Negative.
Neurologic: Negative.
Psychiatric: Negative.

Medical Billing and Coding Forum

Morbid Obesity with documented BMI of 34.9 or below

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“Morbid Obesity” has always been supported by BMI values of 40 or more or 35-39.9 with co-morbid conditions and “Overweight” has always been supported by BMI values of 30-34.99 supports.

In ICD 10, when coding from category E66, there is an instructional note to use additional code to identify the BMI, if known.

Is it appropriate to report E66.01 (Morbid Obesity) with a documented BMI of 34.0? Does a BMI of 34.9 and below support the definition of morbid obesity?

Medical Billing and Coding Forum

Using EGD findings after the visit was documented

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Hi all,

I understand that when it comes to pathology and diagnosis coding, the provider can wait for the pathology report to come back in order to supply a definitive diagnosis. Likewise, as a coder you can code from the path report.

If Dr. A sees the patient at 9am, and Dr. B performs the EGD at 1pm. The coder doesn’t code the notes until 14 days later (long after the patient has been discharged from the hospital). Can the coder still pull the diagnosis from the EGD report for Dr. A’s claim or would the coder have to report the signs/symptoms for Dr. As claim because technically the patient didnt have a definitive diagnosis at 9am??…If this logic is true, it just seems to contradict the pathology rule.

I’m speaking from the pro-fee inpatient side.

Medical Billing and Coding Forum

No Exam component documented

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Need help/advice:

I have a provider who is seeing est. pt’s back for f/u in office so 2/3 I know. But he documents no exam on these pt’s..only a History & Assessment Plan. Is this ok? I feel it’s not best practice but would an insurance auditor or any auditor let this go and only code off the History & MDM?

Thoughts/suggestions any/all appreciated.

Medical Billing and Coding Forum

No IMPRESSION documented

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I would sure love to get a clear answer on this one… I’ve just started coding some radiology and I’m finding that these radiologists do not always document an "impression". Just "findings". Even though the "findings" could explain the signs and symptoms, and are the same diagnoses that they do often include in an "impression" (WHEN they do dictate one). Can I just code from those "findings"? Or stick with the signs and symptoms?

Thanks in advance for any help!

Medical Billing and Coding Forum