Sometimes we see patients from the ER for follow-up wound care. For example a patient got stitches and bandages at the ER for an arm laceration, then was seen by us a few days later for a wound check and bandage change. Is this a subsequent encounter since the patient initially got care at the ER for the injury? Our provider is not employed by or affiliated with the hospital if that makes a difference.
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Tag Archives: Encounter
Z13.32 Encounter for screening for maternal depression
Hello fellow peds coders!
I was hoping for some insight into this new 2019 ICD 10 code, Z13.32 Encounter for screening for maternal depression. The ICD 10 book I have does not give an age or gender restriction, so I was thinking about using it on the Edinburgh screening. However, when I attempted to use it on a newborn male’s record, it got an error saying it cannot be used for males. On the ICD10data website, it says female only. Since there’s a conflict between the website and ICD 10 book, I was hoping for some input from this community.
Thanks so much!
Erin
FQHC E/M for VFC encounter
I have a question. Our provider wants to bill an office visit 99212 when administering VFC vaccines such as the flu shot. We brought up the issue of medical necessity and also that a 99212 is a problem focused e/m and the patients only coming in for the vaccine with no problem. He just wants paid the encounter rate, but yet doesn’t want to have to see the patient either. I do not believe this is allowed red flag for fraud and abuse. Can some clarify. I feel it’s not allowed. If he wants the encounter rate so bad then he needs to see the patient and counsel them on the vaccine and document what he counseled and do a physical exam on the patient.
Pregnancy Testing as part of unrelated encounter
Patient comes in for sinusitis and provider wants to prescribe Cipro, but wants to screen the patient for pregnancy prior to prescription. No other symptoms. Besides the coding for sinusitis as the primary diagnosis —
Would the z32.00/z32.01/z32.02 coding be appropriate to justify the pregnancy test and would you also add Z01.812 (blood or urine testing prior to "treatment or procedure"?
Would the z32.00/z32.01/z32.02 coding be appropriate to justify the pregnancy test and would you also add Z01.812 (blood or urine testing prior to "treatment or procedure"?
Z42.8 Encounter for other plastic and reconstructive surgery following medical
Hello, I am a new pro fee coder and will greatly appreciate your expertise with using Z42.8. Recently, I coded a few cases with Z42.8 and I was wrong, I am not convinced with the answer given and therefore, would like to get your opinion. Case: pt is coming to see a plastic surgeon to discuss a plastic surgery After healed medical procedure for cleft palate (for example). The doctor is saying that the pt is a good candidate and the surgery can be scheduled/considered. I used Z42.8 as the prim dx and then Q code. I was told that I cannot use Z42.8 because pt is not having surgery ‘right now’ or the office note doest not say’ Pre-op visit". But to me, pt and doctor are discussing the plastic surgery. Pt is New to the plastic doctor. May I use Z42.8 as prim? Z42.8- Encounter for other plastic and reconstructive surgery following medical procedure or healed injury. Another case could be: pt has mastectomy done and is coming for discussing a plastic surgery.
Thank you in advance.
Thank you in advance.
Clarification Needed for Annual and Encounter for Adoption Services
Good Morning,
A patient came in for an annual visit and stated that she also needs paperwork completed to finalize an adoption. I am a bit confused on how to code this encounter for the following reasons: the sole purpose of the visit is to have a yearly physical and (2) have paperwork completed for adoption services (which is a mandated service). I chose Z00.00 for the primary code and Z02.82 for the secondary code and I did not append mod-32 to the 99396 since the progress note reads:
CC: Physical/Adoption paperwork
HPI: 33 year old female presents with c/o Annual physical exam. Feels well. She is finalizing an adoption next week. She denies sadness and is motivated. She has no special concerns. She is not on OCPs and has been married for 5 yrs.
I need to know if I am supposed to append the mod for a mandated service since the service was included in the encounter and if Z02.82 is appropriate for an adult who is seeking to adopt.
Your help is appreciated!
Thanks,
Trenisha- Future Certified Coder:confused:
Medicare kicking back encounter
Hello all,
I recently did an audit for a doctors office. The provider ordered TSH, Lipid panel and PSA Screening. He provided only a Z00.00. I coded it out to that because I was always under the impression that for outpatient, Z00.00 can be used for PSA Screenings. I can see why the other two were denied but I am confused about the PSA screen. I have been coding most PSA screens to the Z12.5 but there have been a few over the past few months that only gave a Z00.00 in their documentation. This is the first instance that I have gotten it denied. Any thoughts? I am so confused. Thank you!
HIPAA timeframe for completing documentation for an encounter
This may be an unusual question, but I’m hoping someone out there can guide me to the answer.
The provider at my clinic is from a much older generation. As such, he has been rather slow to embrace EMR and relies heavily on his handwritten notes when examining patients. After the encounter, the medical assistants input his handwritten notes into the patient’s EMR and make sure every scrap of written documentation- from his notes, to the scripts, to any radiology, etc.- has been scanned into the computer and attached to the patient’s chart.
As the coder/biller/auditor, I then code the encounter and check it for accuracy. It is then presented to the provider for his final approval and to be electronically signed. It’s an overly drawn out process for something that really shouldn’t be so complicated.
How long is too long to complete this process? I ask because sometimes we get patients who want all of this documentation in their hands the day of the visit- not just the vitals or a quick summary. Legally, is there a timeframe for us to follow to comply with their request?
Thanks!
Encounter for Hearing Screening-Peds
When we do a hearing screen, we put that diagnosis secondary to the encounter for the routine health exam. I am now getting notification from one particular insurance that this should the primary insurance. Anyone seeing the same?
Encounter for Betamethasone
What DX would you use for injection for Betamethsaone, patient is pregnant and given for fetal lung maturation.