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Tag Archives: history

PSA for history of prostate cancer

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I’ve been receiving denials for patients PSAs with Z85.46 (personal history of prostate cancer). Some commercial insurance companies, including BCBS, is considering this as routine services and is patient’s responsibility. I don’t understand how this is considered routine services and what is the best course to appeal this denial. I cannot change the diagnosis code to C61 because the patients have received treatment, ie; prostatectomy, HDR, and there is no evidence of disease and is not being actively treated for prostate cancer and my physicians are only monitoring the PSA. So my question is how can I fix this??

Medical Billing and Coding Forum

When do pediatric codes become ‘personal history of’ for an adult? Is it 18 or 17?

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Recent discussion on a denial for age specific diagnosis of T74.4XXS (Shaken syndrome) on a patient that had reached the age of 21. So, the question is at what age does the patient move from an active pediatric code to a ‘personal history of’ code? I can’t seem to find a reference any where on this specifically.

Medical Billing and Coding Forum

Establishe pt: Level 4 History, Level 4 Exam, Level 3 MDM

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So many visits by our new provider in seeing established patients are level 4 History, level 4 Exam, and Level 3 MDM, so I have to address this. (borderline level 3/4)
I understand medical necessity is usually determined by the provider since coders lack the clinical piece. I also understand MDM carries the most weight over History and Exam sections. Also, medical necessity is the overarching theme for the visit, beginning with the chief complaint–reason for the visit– and HPI and going through the exam and MDM. I just want to present both sides if I decide to go to the practice manager about this (AAPC side and our new providers side). Our new provider has been coding and seeing patients for 6 years at another practice.
I know this new provider is NOT copy/pasting from one note to another from prior visits in our practice and she is NOT having staff fill in blanks on EMR or NOR using prepopulated sections. I have gone through several weeks of her notes and her HPI and ROS are different for each patient. The ROS relates directly to chief complaint in each section. The exam is based also on reason for visit. Each of the 3 sections are described in relation to the individual patient and their chronic and acute problems.
The new provider in question is seeing patients who were being treated by 2 other of our providers, who just retired. So every condition is new to this new provider/examiner so she spends more time with her patients (new to her, but established to the practice)
So if she is gathering extra info on each patient because she is unfamiliar with their case and needs background info to treat them, does this constitute medical necessity?
In other words, which level would be billed when: History is detailed (level 4), Exam is detailed (level 4) and patient has 2 or 3 diagnoses/symptoms and Rx are NOT given?
Any advice on how to approach this subject with new provider or practice manager is appreciated.. I work at home remotely, so my correspondence is usually via email. Thank you for any assistance you may have. I welcome any viewpoint.

Medical Billing and Coding Forum

Preventive Exam and History of Positive HPV

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Hello All

I have a few patients who calls and complains because they have received a bill from the labs showing they owe money. the patient was seen in our office for their yearly Preventive exam in which I would bill out the 99385-99397 with the Z01.419 (Encounter for gynecological examination (general) (routine) without abnormal findings). I have learned that on the providers side when they submit the Lab codes they are using things like R87.612 (Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)) because in the previous years the patients labs came back abnormal; as for when they have their colpo in the previous year.

So because the provider is putting a problem diagnosis on the lab claim this is where the patients bill is coming from.

I would like to know is this correct billing when submitting claims to the lab??? Or should they be using Z01.411 (Encounter for gynecological examination (general) (routine) with abnormal findings) because we truly do not know if the patient is reflecting positive until the labs come back for this year.

Thanks in advanced

Bev

Medical Billing and Coding Forum

History of pulmonary embolism currently on Xarelto

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Patient is coming into a Gastroenterology practice for rectal bleeding.
The physician orders a colonoscopy but wants clearance prior to the colon because the patient has a history of a pulmonary embolism currently on Xarelto.
The provider has no other information other than that to provide.
How would you code the pulmonary embolism?
Do code a history of or do you code current because the patient is still on medication?

Looking for insight of how others code because we have two different though processes in our office and we are trying to come to a common ground.

Thanks is advance.

Medical Billing and Coding Forum

Detailed History and Detailed Exam support level 4?

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We have a new provider. She always documents a detailed History and Detailed Exam.
Her view is since she is new she is gathering detailed info on all her patients to get to know them. She usually gives an exam with at least 6 elements since these patients are new to her.
Her Medical Decision Making often has 2 or 3 dx without RX.
I’m often finding low level medical decision making.
Would these office visits be scored as level 3 or 4?
Thank you

Medical Billing and Coding Forum

Office Visit BEFORE Colonoscopy with Dx of Personal History Of Colon Polyps

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Someone (and I forget where I heard this) told me it is acceptable to use Z09 as primary dx code when a patient comes into office with dx of Personal History Of Colon Polyps before a colonoscopy in order to get the office visit paid for. So you would bill Z09 as primary code and Z86.010 as secondary code. Anyone know if this is correct?

Medical Billing and Coding Forum

Getting history information

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When reviewing a patients family and social history and there is no qualifying or pertinent information related to the HPI or chief complaint, but it is documented by the provider that they were discussed, if all other areas of comprehensive history are discussed, will those qualify the PFSH as complete, allowing for a comprehensive history?

Medical Billing and Coding Forum

Coding from Social History

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HPI: Patient presents to ED due to fall from ‘drinking’. Has shoulder pain.

In the social history the provider gives more details. Drink 3-4 beers a day, uses cannabis, smokes tobacco, etc. Can this social history be pulled into the coding?

Or can I only code alcohol use (Z72.89) since the HPI only states ‘drinking’?

Medical Billing and Coding Forum