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2016 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

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

Coding E&M for substance abuse Facility

Should a pre-admission assessment (99202-05) for a substance abuse facility be coded solely based on the time spent doing the assessment? Please advise. I am referring to section 4 in the attachment.

Evaluation and Management coding score sheet 2.12.2018.pdf

Medical Billing and Coding Forum

Diagnosis Coding and Medical Necessity from Radiology Reports in the ED Facility

I review emergency department charts on the facility side and I often have to review charts from our denials department. I have a case where an MRA of the neck was ordered with a dx of arm numbness and TIA. The nurse is asking if TIA can be added in the Attending’s final impression to support medical necessity for the MRA. The attending reviewed the findings from the radiologist "Diffuse white matter signal abnormalities in the bilateral cerebral cortices, most likely related to chronic microvascular disease. There are no signs of acute ischemia, hemorrhage, or mass." And, the attending documented that the MRA was negative in his progress note and left his final impression of arm numbness.

These are my questions:

1. Can the dx of R93.0, abnormal findings on diagnostic imaging of skull and head, NEC, be reported. Please note: the attending does not address these findings and states the MRA is negative.
2. Can the TIA dx be reported if it is only found on the order? There are no other signs and symptoms in the medical record to support medical necessity for the MRA of the neck.
3. Should I query the provider?

Medical Billing and Coding Forum

Emergency Room Facility E/M required documentation

Some of our ED physicians are just documenting an HPI, ROS, PE, Med, PFShx, and final diagnosis in their notes. The ancillary information flows into the EMR, but they do not document any further information as to the patient’s treatment, care or outcome of the visit, no Progress note or MDM. For the Facility coding, is this enough information? I feel there needs to be a full story of the patient’s visit in their note. If patient is transferred to another facility, there is no mention of that in the note. The physicians feel we can find that somewhere else in the EMR. Any help is appreciated, we just started coding for this group and are struggling. TIA.

Medical Billing and Coding Forum

Bring Full Functionality to Your Medical Facility With a PACS RIS System

It is hard to imagine how the average medical facility could survive without their PACS workstations. By making the switch to a digital medical environment through the use of PACS RIS systems, you can enjoy the full functionality that comes with being able to store, view, distribute and archive your medical images and records quickly, easily, and cost effectively.

A fully effective PACS RIS system is offered by Candelis with their Candelis PACS, and most notably the Candelis Imagegrid. The Candelis Imagegrid offers the full range of features that every medical office and facility can use to improve workflow and offer better patient care.

Candelis Imagegrid combines the software you need with a state-of-the-art server that acts as a storage warehouse. The storage capacity of the Candelis Imagegrid can range from one to tens of terabytes, and can be sized to fit your medical facility’s specific needs both now and in the future.

This Candelis PACS system also allows for fast access of digital medical images, and in the process simplifies the operation and management of those digital image files while all the while protecting those images with HIPPA compliant protocols in place.

Because Candelis pacs works on a Dicom framework, it also allows for greater flexibility in use of a wide variety of digital image modalities, including high-volume 64-slice CT studies, to be read by the same pacs workstations. By basing the system in Dicom, the appliance can easily move, route and store your medical digital images effectively both onsite as well as offsite.

The Candelis system also allows for a great deal of customization in teleradiology. You can set the rules for automatic routing of medical digital images to reading physicians located both on and offsite as a matter of course. One of the best timesaving features of the Candelis PACS software is that it can be set for automatic storage to a remote server, thus making sure you are in compliance with HIPPA standards regarding archiving of patient medical records.

Pacs ris systems such as this also make anytime access to medical digital images possible. This means that offsite consulting physicians, even those of different continents, can have access to the same patient records as you do, in a secure environment as outlined by HIPPA protocols. All of this flexibility in use comes with no additional personnel costs, making the PACS RIS systems very efficient, and bringing a smoother and increased workflow to your medical facility, regardless of its size.

Wayne Hemrick writes about the advent of future technology. In this article he writes about the PACS RIS system.

How Can Radiology PACS Help Your Medical Facility Run More Efficiently?

Making the switch from film images to digital medical images is a great way to improve the work flow and efficiency of your medical office. You can save a great deal of time and therefore money by making the switch to digital imaging. Radiology PACS help you accomplish this.

Radiology PACS are Picture Archiving and Communication Systems that allow you to produce, view, archive and transmit digital images. Digital radiology systems utilize both specialized software and hardware, yet many of the systems can be run on personal computers and networks with which you likely are already familiar.

Like all digital products, the cost of radiology pacs systems has dropped over the past several years. This means that Radiology PACS are now within the reach of small to medium-sized medical offices and facilities.

Storage of your digital medical images will also save your medical facility money. In the past, prints had to be made, which were then stored in file folders in large storerooms. It was also a big task to retrieve film images, because you had to wade through all of the files to find the ones you needed. This is a thing of the past with digital radiology systems. With a couple of mouse clicks, you can sort through thousands of digital images files to find the one you want in a matter of seconds. Costs typically associated with storage, including storage space, paper, files, as well as chemicals used to print film images, are completely eliminated with digital radiology systems.

Radiology PACS also help you stay in compliance of HIPPA regulations for the storage of patient records and medical images much more easily than in the past, when up to seven years of hard-copy records had to be stored and backed up. Digital images can be backed up onto CDs and DVDs as well as offsite archiving on hard drives and in databases by using radiology pacs systems.

Radiology pacs systems also allow you to take advantage of teleradiology, where digitized medical images and records can be sent to authorized personnel via the Internet. PACS enables physicians anywhere with Internet service to access medical digital images, thus enabling real-time collaboration with physicians down the hall or around the world. In this way, radiology PACS benefits patients, by giving them better care at a fraction of the traditional cost.

Another advantage that comes from using digital radiology systems is that it utilizes the same computer technology with which you and your office staff are already familiar. Computers are turned into workstations with radiology systems software. Peripherals such as scanners and printers are used in conjunction with radiology pacs systems to allow you to scan hard copy documents and turn them into digital images, or to print out digital images.

All this efficiency is possible through the use of PACS and digital medical imagery.

In this article Jonathon Blocker writes about radiology pacs systems.

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On site detox facility coding.

Hello. Can anyone give me some advice on coding for rehab centers. This facility would provide group meetings (DBT and relapse prevention), therapy by LISW, medical direction and detox on site by MD. Also, if patients stay overnight is this considered inpatient? I work in a psych and addiction outpatient office and my doctors are considering ideas to expand. We have many suboxone patients. Any advice or direction to resources that would help me with this is appreciated.

Medical Billing and Coding Forum

routine healing surgical wound, subsequent care at second facility

I need help getting started on the right track for coding a healing abdominal surgical wound. This patient had lysis of adhesions two days prior to transfer to another hospital. The patient was transferred for an unrelated condition to the abdominal surgery, nevertheless did receive attention to the wound which included removal of some of the staples. There were no complications of surgery, so where do I start in looking for the proper code for the abdominal wound. Is it considered a laceration and what external code would be appropriate?

Medical Billing and Coding Forum

Discover about Effects Of a Dicom Viewer To Your Medical Facility

If you are going to use digital medical images, the first sugestion for you is you should obtain a dicom viewer. You can use dicom viewers as basical software applications and can place them on a computer running Windows, Mac, or Linux. You can also access them online by using a web based dicom viewer, then you computer will be allowed to read digital medical images. Using a dicom view in the course of work can be advantageous in some ways.


Flexibility

 

A dicom viewe allows you to see medical digital images taken from a variety of modalities. You can see x-rays, CTs, MRIs, ultrasounds, endoscopic imaging, mammograms and others with a viewer.

 

Immediate Access


One of the best benefits that comes from using a dicom viewer is the speed with which you can access the digital medical images that you need. Instead of trekking down to a storage area to search through thousands of records to find the ones that you want, you simply search using your computer, and the images come up instantly.

 

Through the use of a web based dicom view, you can also have speedy access any where you are. You are no longer tied to your desk at the office, but can remotely access the medical images that you require at your convenience through the use of a web based dicom viewer.

 

You can also create a workstation with the addition of PACS software to your computer setup. This allows your web based dicom v to send and receive medical digital images, enabling cost-effective consultations with physicians located nearly anywhere in the world, or simply sending medical records down the hall to a colleague with a web dicom viewer who is on your local area network. A web dicom viewer also allows you to back up your patients’ medical records in a secure digital environment, both on-site and to off-site locations, for excellent disaster recovery and for meeting compliance with HIPPA regulations concerning digital medical imaging archiving.


Improved Image Viewing

 

With film medical images, what you see is what you get in terms of image quality. With a dicom viewer, you can enhance digital medical images for contrast and clarity. You can see, by setting your dicom view for higher resolutions, digital medical images in much greater detail than ever before.

 

Lower Cost


As with all types of computer software and hardware, the price of fully-functional dicom view or web dicom viewer has come down extensively in price since digital imaging was first introduced to the medical field. Now smaller medical offices and clinics can step up to affordable digital medical imaging with a web based dicom viewer.

 

 

In this article Jonathon Blocker writes about dicom viewers.

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