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

Reviewing behavioral health & AODA notes in Wisconsin

I started a new coding position at a small clinic that offers behavioral health and AODA counseling. Former billers/coders did not have access to notes or encounters because the provider took care of things herself but there have been many changes to staff. I have access to our AODA notes to make sure certain criteria has been met but our other counselor does not want anyone to have access to her notes; she goes as far as typing them up is Microsoft Word and prints off the note to place in a paper chart and deletes what is typed even though we have an electronic system. I know there are certain policies in place on who can have access to what but I am getting mixed messages from co-workers and superiors on who should be able to review what type of note. Can someone tell me where I can find documentation that states the billing/coding department can review such notes and what criteria needs to be met so as a facility we do not get dinged when an audit occurs.

Thank you,
Lisa

Medical Billing and Coding Forum

Modifiers and progress notes

Hello!

Our office has always updated progress notes to match any time a modifier was added to a claim, but we have talked to a few other offices who have said that auditors do not care about whether the modifiers on the claim, are also reflected on the progress notes. They only care whether the services & documentation support the use of a modifier. Can anyone confirm whether or not if a modifier is added to a claim, it also needs to be added back to the note?

Thank you!

Medical Billing and Coding Forum

Use ICD-10-CM Excludes Notes to Improve Coding

Excludes 1 and 2 notes often hold the key to preventing claims denials. There are two type of excludes notes in the ICD-10-CM classification system: Excludes 1 and Excludes 2. Medical coders need to understand the meaning of these notes because they are integral to correct coding, and payers are beginning to deny claims based […]

The post Use ICD-10-CM Excludes Notes to Improve Coding appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Progress Notes

Hi, I am currently a CRC coder and part of my job along with chart reviews is to re-write progress notes and to do addendums for the providers. I am not a clinician but my company requires us to re write plan of cares. We also have to mention stuff that was not mentioned. Example would be “continue to monitor salt intake”, “reduce sedative from whole pill to half of a pill” for sedative dependence, even though not mentioned and even though the provider did not specifically state that anywhere on the date of service or any other date of service. We are also told to use plan of care from previous visits to use for another date of service. I really don’t feel this is legal as a coder. Again, I am not a clinician and did not have a face to face encounter with the patient. My boss says that it’s okay to do this as long as the provider signs the notes and adds it to his chart. Is this legally okay? Please help.

Medical Billing and Coding Forum

Diagnosis on signed order and not documented in provider notes

When looking for medical necessity for ancillary services performed during an ED or observation encounter, if the attending provider signs his order with a medically necessary diagnosis and fails to document accordingly in the record, is it safe to assign that diagnosis to cover? Are there any Medicare guidelines I may be able to refer to about this?

Medical Billing and Coding Forum

Exclude 1 notes N85 series can’t be coded together with N86

Dear All,

Need some help to find why, N85.00 can’t be coded with N86. There is an exclude 1 note in the ICD 10 guidelines; however, while informing our doctors they want to know the reason. Our OB saying, these two conditions doesn’t have any relation, then why we can’t code together.:confused:

highly appreciate your help in this regards,

Thanks a lot

Sherin

Medical Billing and Coding Forum

Audit Risk When 1 Dx Code is Listed on Claim When Multiple Exist in Notes?

My employer is having software issues and a (hopefully temporary) fix has been proposed to include only 1 Dx code per claim. Are we increasing the risk of getting audited? We are a community mental health facility and serve a high Medicare/Medicaid population.

Thank you for any assistance provided!

Annette Vesey, CPC-A

Medical Billing and Coding Forum

Provider treated patients- did not complete notes and relocated

We have a nurse practitioner that treated patients in our rural health clinic however did not complete some of her notes in EHR for them. Can another provider within our organization (physicians with same tax id) sign off on those notes? And for the patients whom she did not create a note, what is protocol for that? I was given instruction if physician relocated to mail them copies of records to sign and return via certified mail for a paper trail? Does this seem typical? Thanks in advance!

Medical Billing and Coding Forum

Repetitive notes

Good afternoon
I have several Provider’s whose notes are obviously a copy and paste. This is a grave concern for me, when auditing their coding, because the notes are never customized to fit the current visit. From the consultation or IE, and every F/U visit, the wording doesn’t change, so when I’m checking to see if they’re meeting the required elements for the level of service billed, it’s all incorrect. How do I get them to document exactly what was done with the patient on any given visit?
Thanks

Medical Billing and Coding Forum

Physician delegates to sign off their charts notes

I need help!

Since our physicians are so busy they suggested that we assign delegates to sign off their charts notes. The CMS guidelines for signature requirements does not really mentioned delegates, is this even legal to assign someone to sign off their chart notes? I do not really agree with their suggestions but if there are guidelines out there that I do not know please share them with me.

Thank you in advance

Josephine

Medical Billing and Coding Forum