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

time out procedure, do you just document in the emr or do you also keep a form

I work on a unit the does endoscopy procedures. Before each procedure the staff does a time out to confirm, the correct patient, procedure, allergies, etc. We have been keeping a form to document the time out was done and also documenting in the patient’s electronic medical record. Do we need to keep the form and for how many years or is a statement in the emr sufficient? Thank you for your help.

Medical Billing and Coding Forum

Drug code J0178 being denied for not being billed on the same claim form with 67028.

Humana denied for not having 67028 billed together on the same claim form with drug code J0178. We do a correction by adding the J0178 to the same claim form where 67028 was billed. Then, Humana come back denying for the same reason.

Have you guys experience this issue? Do you guys appeal? ( I have appeal this denial and I still get a response stating "First decision stands".

Medical Billing and Coding Forum

Patient refuse to sign financial form

A new staff checked in a patient with out having the patient sign the financial form.

The patient saw the doctor already and refuses to sign the financial form after.

The purpose of the financial form is mostly educational about what deductibles, copays, co-insurances are and that if they do not pay what they owe they’ll be forwarded to collections.

Can I still bill the patient for their deductibles, co-insurances, copays regardless if they signed our financial form since it’s what we have to do per our contract with their insurance?

Medical Billing and Coding Forum

ROS intake form

If a patient fills out this intake form (circles what symptoms they’ve had since their last visit) and the provider goes over the form and documents a complete ROS, does the intake form need to be kept on record, filed in the patients chart or can this be shredded since the provider has went over all pertinent review of systems? There seems to be some confusion on this.
Thank you in advance!

Medical Billing and Coding Forum