Click here for more sample CPC practice exam questions with Full Rationale Answers

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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

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Day 2 of HEALTHCON Regional Ends on a High Note

Day 2 of AAPC’s hybrid regional HEALTHCON in Denver, Colo., Aug. 3-5, got off to a great start with a discussion on how to create a work/life balance — something that many people struggle with possibly even more since being resigned to work from home because of the public health emergency. The irony was not […]

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AAPC Knowledge Center

HEALTHCON 2021 Ends on a High Note

AAPC’s posse pulls off a hootin’ good time for all! AAPC HEALTHCON 2021 attendees finished up day four of conference, heads whirling with essential information they will take back to their workplaces; hearts full after connecting with their peers; and bodies destressed after an inspiring talk from motivational speaker Denise Ryan. Whether remote or in […]

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AAPC Knowledge Center

Help with chemo port coding op note

Can someone experienced with this type of coding please assist, as this is a whole new ball-game for me. MCR pat w/dx rectal cancer. I extracted the pertinent info & abbreviated from chart note to ease in assistance.
Summary:
* Access type: Left Other AVF/AVG.
* Subclavian vein: temporary dialysis catheter insertion.
Radiation Totals:
Total fluoro time: 1.0 min:sec
Technique:
——The R upper extremity and L upper extremity were prepped using Chloraprep R and L neck, chest to nipple line. Local/MAC sedation administered by CRNA services administered w/trained independent observer in attendance to monitor level of consciousness & physiological status. The subclavian vein was accessed in an antegrade fashion from L. After carefully reviewing the diagnostic fistulogram, it was decided to proceed w/intervention. Sheath was removed & upsized for 8-Fr sheath.
Intervention:
A catheter was placed over the wire in the subclavian vein. Temporary dialysis catheter insertion is positioned in the vessel. MedCOMP CT Implantable Port – REF #L MRDP80AMN 8 fr. 61cm MS Dignity CT Port Lot #: MNDM230 Exp. 07/31/2023 implanted into L chest via L Subclavian Vein.
The puncture site was closed using Incision site to L chest closed w/Dermabond.
Findings: Subclavian vein: normal.

I’m thinking 36561 and 77001 would be appropriate. Doctor listed 36299 (unlisted) for vascular injection.
Validation/correction would be appreciated.

Medical Billing and Coding Forum

op note help needed

Laparoscopic placement of a peritoneal dialysis catheter( Flex-Neck Classic , 2 cuffs adult standard coiled- MeritMedical)

49324 is what i have anything else ??? THANKS SO MUCH

After induction of general endotracheal anesthesia, the abdomen was prepped and draped in standard surgical fashion. Attention was turned to the left upper quadrant where a 5 mm port was placed under vision with the cvamera in; The abdomen was insuflated with CO2 and the head of the bed was lowered.
The right lateral transverse incison was made over the rectus abdominus and dissection through the anterior layer of the muscle fascia was made: the Luke guide assembly is placed with the tip of the metal spear towards the pelvis with a 45 angle . The metal piece is then removed and the expandable sheath is left in place, secured with a clamp . Serial dialtion of the tract is made with lubrified dilators. The stylette is placed in saline and into the catheter and the catheter with the stylette inside is placed through the expandable sheath, all under vision towards the pelvis, taking care to maintain the curve of the catheter. The stylette is removed and the first cuff is advanced in the muscle with the help of the implantor tool. The tunellor tool is then used to tunel the catheter and the second , distal cuff in the sq. The position of the tip of the catheter is checked and then the abdomen is deflated.

Medical Billing and Coding Forum

Missing diagnosis on Op note.

I have operative notes that do not include any diagnosis (pre or post Op).

Being "old School" I suggested an addendum to the provider to update his note prior to billing. I was told that according to the AMA you can take the diagnosis from the H&P. That just doesn’t ring true. I might be able to see it for an ASC charge as the facility is getting the H&P as part of chart paperwork but even that is a stretch for me.

I started coding before EMRs, and live by the rules of, not documented not done and stand alone documents, but to make sure I am looking for credible references to

prove that a operative note must have a diagnosis listed. I would love to see anything that the AMA has on this topic, but I have not been able to get into the website.

Can anyone help me?

I have JCAHO Standard IM.6.30 so far.

Thank You

Medical Billing and Coding Forum

Can someone review chart note to see if I’m on the right track?

Hello again, colleagues,
After receiving helpful advice from a fellow member, have come across another scenario that is baffling due to my limited experience in this type of coding.

PRE-OP DX: ischemic ULCER RIGHT LATERAL FOOT
post-op dx: osteomyelitis WITH ISCHEMIC ULCERATION OF RIGHT LATERAL FOOT INVOLVING 4TH AND 5TH METATARSAL AND CUBOID BON

Performed:
1) debridement of right foot to include skin & soft tissue and cuboid bone right foot.
2)Right 5th metatarsal resection, partial
3) right 4th metatarsal resection, partial

Description: (extraction of pertinent verbiage). Ischemic ulceration was then debrided over the lateral foot. This clearly involve the 5th metartarsal bone.
Wound did extend more medially w/involvement of the cuboid bone as well as the 4th metatarsal. These were all sharply debrided back with a rongeur and
the 5th metatarsal was resected along with a portion of the 4th metatarsal. Would was packed w/saline-good bleeding was appreciated from wound bed.

My efforts: I see a debridement here in #1, but not sure about the two codes for #2 and #3. I’m thinking 28122, 28122. (The 5th metatarsal was resected, with a portion
of 4th?), so not sure about choosing the same code for both procedures when one was a partial.

Can anyone offer guidance?

Medical Billing and Coding Forum

Writing note in books for exam

Hi there,

I am sitting for my CPMA exam in a couple months and I am reading some conflicting info on what is allowed to be written in my code books. Per the FAQs: Handwritten notes are acceptable in the coding books only if they pertain to daily coding activities. Questions from the Study Guides, Practice Exams or the Exam itself are prohibited. Tabs may be inserted, taped, pasted, glued, or stapled in the manuals so long as the obvious intent of the tab is to earmark a page with words or numbers, not supplement information in the book.

No materials (other than tab dividers) may be inserted, taped, pasted, glued, or stapled in the manuals.

So – I want to write specifics on the laws, like the Stark Law and Anti-Kickback Law, such as their differences, fines, ect. Also writing stuff specific to auditing (which I am sure if fine as that is specifically related to daily activities of an auditor). So what do my fellows think about writing notes on the laws/penalties/fines/compliance plans and all that jazz. There’s so much info and I want to be prepared!

Thanks!
Erin :)

Medical Billing and Coding Forum

Two Doctors on One Note, Not Assisting or Co-Surgeons

Hello,
I have a provider (we’ll call her Dr. A,) who performed an office visit, she also dictated in her note that "Dr. B performed OMM during the visit." Dr. A dictated the procedure just like she would if she had performed it herself. We asked Dr. B to do a separate note to dictate his procedure and to sign it, he has relayed to us that we shouldn’t need a separate note for his procedure. I am unable to find any articles or resources to clarify whether or not a provider can document another provider’s procedure and sign for it. If anyone has anything that can help, I would surely appreciate it.

Thank you,

Mary

Medical Billing and Coding Forum

need help with code for debridement note

Hi, colleagues; after being away for some time returning in a new position, and need some CPT coding guidance. Here’s an extracted chart note: This will probably be easy for those of you who deal with these procedures regularly.

LT great toe wound is suspicious for an infected gouty arthritis versus osteomyelitis.
Description of Procedure: After informed consent PAT was taken to operative suite & sedated by anesthesia service. LT foot was then prepped draped standard fashion. We then anesthetized the base of toe & following this explore the tip of toe wound. This clearly extended to distal phalanx which was gently debrided. Cultures were obtained & specimens were sent for biopsy. Dressing was applied following a counterincision on lateral aspect of toe where IV tubing was placed for drainage. Patient tolerated procedure well/discharged home in stable condition

No measurements are supplied.

I see debridement and then an incision for drainage. Are they both considered components in the debridement process, and if so, choices are in the 110XX code range? Also, might 10140 be a consideration?

Medical Billing and Coding Forum

Does every progress note stand alone

Does every progress need to stand alone ? I was taught that was the case but ,now I am being told that I can go anywhere in the patients chart to pull the information. For instance the patient is following up for an injury. The first vist is very detailed but the follow ups are not as detailed to assign the most specific ICD10 code. Can I use the details in the first note for a more specific code selection on my date of service ?

Medical Billing and Coding Forum