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

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CPC Practice Exam and Study Guide Package

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

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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

Death of the Documented History, Rise of the Patient Advocate

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

Greatest Medical Record Heist in History

A whistleblower lawsuit alleges the University of Chicago Medicine shared hundreds of thousands of medical records with Google that retained identifiable information. Chicago-based law firm Edelson PC filed on behalf of a former patient and claiming this is a direct violation of HIPAA given the data-mining tech giant has access to a plethora of public and nonpublic information that […]

The post Greatest Medical Record Heist in History appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Wiki initial hospital visit with EPF history

Hello Guys ,

still a big confusion .can anyone help with this :

If all three key elements of the minimum initial hospital visit are not met, would you instead submit subsequent hospital codes ? (Ex: initial hospital visit case is leveling out to History – EPF, Exam -EPF and MDM – Moderate). Being the lowest level is detailed/detailed/low, I’m not sure how to proceed. Any insight appreciated, thank you!

please provide reference.

Medical Billing and Coding Forum

History of

Provider documents:

Patient has a history of iron deficiency, chronic kidney disease, and an elevated alk phos level, all of which will need rechecked. She also is due to have cholesterol checked. Recheck lab work at this time.

Provider codes as current conditions not history of. Would you code these as history of or query to find out if they are actively treated and if so ask the doctor to make a correction to the documentation.

Medical Billing and Coding Forum

history other than patient/mdm

I have a NP who works pediatrics and does a wonderful job of documenting if her HPI/ROS is obtained from the patient (15 year old, etc.) or if it is obtained by someone else (Mother states…).
We have a debate in our office on if this should be counted in determining the E/M level in the "Data" are as obtaining history from someone other than the patient. They feel that this should only apply to pts whos medical condition prevents the patient from giving information and it does not pertain to patients who are prevented because of their age.
I disagree. I feel that regardless of WHY the provider can’t get the information directly from the patient, it is still second hand information that adds a level of difficulty to their MDM.

Does anyone have documentation and/or sources I can refer to in sorting this out?

Medical Billing and Coding Forum

Past, Family, and/or Social History (PFSH)

Have some confusion in understanding the proper way to document a PFSH. I have a provider who only documents " Patient’s medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate " in all his visits

Per E/M guidelines: You do not need to re-record a ROS and/or a PFSH obtained during an earlier encounter if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.
You may document the review and update by:
• Describing any new ROS and/or PFSH information or noting there is no change
in the information
• Noting the date and location of the earlier ROS and/or PFSH

by him signing and dating below, is this sufficient to account for a PFSH????

This is an example of the providers documentation:

Chief Complaint
Patient presents with

• Hypertension

*
*
HPI patient is here for htn,. He has been on medication in the past. But has not had insurance. Now he was unable to past a dot physical to drive big rig.
*
Review of Systems
Neurological: Positive for headaches.
*
*
*
Patient’s medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
*
*

Objective:
Physical Exam
Constitutional: He is oriented to person, place, and time. He appears well-developed and well-nourished.
Cardiovascular: Normal rate.
Neurological: He is alert and oriented to person, place, and time.
*
*
*
Assessment:
*
1. HTN, goal below 140/90 losartan (COZAAR) 50 MG tablet
* DISCONTINUED: losartan (COZAAR) 50 MG tablet
*
RTc in 1 week for bp control.

Electronically signed by XXXXX, DO at 10/23/2017 *9:40 AM

Medical Billing and Coding Forum

Oncology coding – active vs history

Hello fellow coders ~ I’m trying to find an answer to oncology coding. I have a patient who has finished chemo treatment for breast cancer. She has had the all clear, but is on a 5 year oral chemo treatment for maintenance. How would this be coded?? History of or active treatment? Any help would be greatly appreciated!!

Medical Billing and Coding Forum