Laureen shows you her proprietary “Bubbling and Highlighting Technique”
Download your Free copy of my "Medical Coding From Home Ebook" at the top right corner of this page
2022 Hospice proposed rule would help with addendum statement snags, but other problems remain. In the Hospice proposed rule, published in the April 14 Federal Register, the Centers for Medicare & Medicaid Services outlines these changes to the election statement addendum that was implemented on Oct. 1, 2020. Three vs. Five Days In the 2020 […]
The post Hospice Addendum Problems Solved appeared first on AAPC Knowledge Center.
The clock is ticking for OASIS matching edits to begin returning claims. Another week has gone by under the Patient-Driven Groupings Model with no solutions announced for OASIS submission problems with the new iQIES system. Why Are OASIS Files Being Rejected? At press time, 94 percent of home health agencies (HHAs) had gotten onto the […]
The post iQIES Problems Derail Some PDGM Claims appeared first on AAPC Knowledge Center.
Appointment for WWE – new patient. 99386
Does it support an extra office visit? Please see the doc below
HISTORY:
44 year old female c/o having malodor clear discharge since IUD Insertion.
Also c/o LLQ pain prior to having kids. Patient had colonoscopy done benign. Pain went away during pregnancy. Don’t know if she had pelvic ultrasound or not.
*
Location occasional back pain. Gained 30 pounds over the past 1 year.
Quality pressure like.
Severity 5/10 pain scale. There most of the time.
Duration more than years now.
TIming not related periods.
*Associated signs/Syptoms heavy period prior to IUD
*pt reports to have IUD Mirena insertion about 3 years ago. Patient used to have dark heavy periods with clots. All her sisters had this problems. IUD helped with pain.
no pain with intercourse. Patient’s husband had vasectomy and IUD Mirena for contraceptions.
Patient does leak urine when coughing or sneezing. Last 2 pregnancies, her uterus dropped. She has to cross her legs whenever she cough or sneeze or laugh. Feel like getting worse.
*Her last papsmear was 3-4 years. Her last mammogram was 3-4 years.
Patient works as: office manager for court recording agency.
*Cesarean Section x2 (4 year old daughter and 6 year old son).
*SOCIAL HISTORY: not smoked. She reports that she does not drink alcohol and denies used illicit drugs.
*Depression screening:
During the last month, patient denies any feeling down, depressed, or hopeless. Patient Report normal interest and pleasure in daily activities. Patient denies any suicidal ideation or thought of harming anyone.
*MEDICAL HISTORY:
Chronic LLQ pain *
Hernia, inguinal, bilateral *
SURGICAL HISTORY:
AUGMENTATION OF BREAST * 1996
BASSINI REPAIR OF INGUINAL HERNIA * *
* x2 bilaterally
CESAREAN DELIVERY ONLY * *
* x2
FAMILY HISTORY:
Stroke Mother 79
Cancer Father 60
* prostate cancer. died from it.
REVIEW OF SYSTEMS:. General: No weight change, generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Breast: No noted lumps, no tenderness, no swelling, no nipple discharge.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no emesis, no melena.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia. Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PHYSICAL:
*
LMP:
Patient’s last menstrual period was 12/20/2018.
*
Vitals:
BP: 130/73 | Pulse: 81 | Temp: 97.3 °F (36.3 °C) | Resp: (not recorded) | Height: 160 cm (5′ 3") | Weight: 72.6 kg (160 lb) | Body mass index is 28.34 kg/m².Body mass index is 28.34 kg/m².
*
PHYSICAL EXAM:
Awake, alert and oriented to person, place and time.
Psychiatric: alert, does not appeared depression, well groomed, good eye contact
ENT: Head normal configuration & texture. Nose normal color, no discharge. Teeth present and in good dentition,
Eyes: PERL, normal eye contact.
Neck and lymphatic and endocrine: active range of motion, thyroid non palpable lesions, normal size and consistency,
Breast and Skin: inspection normal size, symmetrical, nipples symmetrical and everted, no masses palpated and no discharge, no palpable enlarged lymph node supracervical and under axillary areas,
*Cardiovascular system: Thorax symmetrical expansion with respiration, RRR
Gastrointestinal: normal bowel sounds and Normal Bruits, no tenderness and masses with superficial and deep palpation,
Respiratory: clear lung sound bilaterally
*Musculoskeletal: normal range of motion, normal strength of upper and lower extremities. No tenderness noted in the lower back bilaterally
lower extremities showed Normal ranges of motion,dtr 2/4 patella bilaterally.
*Genitourinary: Normal external genitalia of labia, clitoris, urethral orifice, introitus.
3rd degree prolapse anteriorly, 2nd degree uterine prolapse.
External hemorhoid.
ASSESSMENT/PLAN
*1. Chronic pelvic pain in female
– US PELVIS W/ TRANSVAGINAL AND DOPPLER; Future
*2. Encounter for annual routine gynecological examination
– THINPREP PAP W IMAGER AND HPV RNA, HIGH RISK, E6/E7, TMA; Future
*3. Breast cancer screening
– SCREENING MAMMO BILAT DIGI W/CAD; Future
*4. Cervical cancer screening
– THINPREP PAP W IMAGER AND HPV RNA, HIGH RISK, E6/E7, TMA; Future
*5. BV (bacterial vaginosis)
– metroNIDAZOLE (FLAGYL) 500 mg Tablet; Take 1 tablet by mouth every 12 hours for 7 days. Dispense: 14 tablet; Refill: 0
*6. Urinary, incontinence, stress female
*7. Grade I hemorrhoids
– hydroCORTisone (ANUSOL-HC) 25 mg Suppository; Unwrap and insert 1 suppository rectally 2 times a day. Dispense: 60 suppository; Refill: 3
kegal, frequent intercourse, consider surgery dependent on pelvic ultrasound.
*PATIENT WILL FOLLOW UP WITH GI AND DR. ALEXANDRA.
*HIGH phq 8-DENIES SUICIDAL.
*NEED ULTRASOUND FIRST, IF PAIN PERSISTED CONSIDER DIAGNOSTIC LAPAROSCOPY
Thank you in advance Cheri
Thanks
Does CPT code 51701 need to have a modifier attached?
Example 1: Patient with Medicare insurance has vulvar lesion with postmenopausal bleeding that is biopsied. Codes used were 99213-25, 51701, 56605-59, & 58100-59. For Number 3 Office Call, straight catheterization, biopsy of vulva, & Endometrial biopsy.
Example 2: Patient with BC/BS insurance comes in for urodynamics testing, no Office Call. Codes used were 51701, 51728, 51741, 51784, 51797. For straight catheterization, complex CMG with bladder voiding pressure, complex uroflow, EMG, abdominal pressure, add on code.
I did not use one because the CPT book does not list this code as a separate procedure and I used a 25 modifier on Example 1 for the Office Call. I’m getting more cofused the longer I look at this and try to figure out why. Please help!!
Thank you!
Benewah Community Hospital, situated in St. Maries, Idaho, faces hard times after it implemented new software that caused several heavy billing problems. The hospital in Benewah County worked with Cerner for over a year to implement the software. However, problems with the application didn’t manifest until after the hospital went live following a software update. The hospital can properly bill private insurers, but not Medicare.
The post Idaho Hospital Has Software Glitch Causing Billing Problems appeared first on The Coding Network.
Everyday activity change is generally needed in order to implement a proper diet program to everlastingly eliminate excess body weight. An effective healthy weight loss diet can be a real struggle with this eat and run society. Above the different unhealthy processed food items, there is a huge number of rapid weight reducing plans to baffle people. Unfortunately, nearly all rapid losing weight plans will not everlastingly keep off excess weight. The results are only short term.
An ideal weight reduction program might make folks look and feel great. Furthermore, a person’s future well-being will depend on his or her present healthiness. As an example, people with an appropriate body mass index will lower her or his probability of future vital health issues including heart disease as well as sugar Diabetes.
Prior diet program endeavors possibly will have not been successful. Do not be discouraged. A healthy diet program happens to be an everlasting solution that will involve daily routine modifications, a support group, slowly slimming down and remaining on track until every goal happens to be achieved. At this point, take into account a long term approach for a proper weight reduction plan which means no quick weight loss simply a slow healthful permanent way of life change. Those pounds will steadily vanish plus stay away forever.
The first thing a person should adjust is to keep metabolism high through the day. Ingesting three big portions of food each day can produce a yo-yo influence on people’s metabolism rate. But, eating smaller proportions of healthful munchies and meals during the day will keep a person’s metabolic rate high and that aids in slimming down following a healthy weight reduction plan.
A proper weight reducing program will begin at sunrise consuming a nutritious morning meal. Eating eggs and steak will be okay as long as that steak happens to be from grass-fed cows plus the eggs will be out of open range chickens. The explanation happens to be since food products out of open range chickens and cattle have an incredible amount of minerals, omega-3 fatty acids and vitamins as well as less harmful fat when compared with confined chickens and cattle. Possibly a quick small morning meal might be required. In that case try unflavored oat flakes. Add a little organic blueberries and cinnamon. This specific meal will be filled with fiber, vitamins, antioxidants and minerals that assist with loss of weight and lower people’s risk regarding future cancers, tumors and other health conditions. Adopting a proper healthy weight loss diet should by no means demand a person to give up delicious foods. Just change from a not healthy sugary morning meal over to a healthful breakfast. This type of notion should be adhered to in regards to rest of the meals throughout the day.
One more recommendation regarding an ideal diet plan is to ponder what beverage tends to be ingested during the day. A single twelve ounce container of sugary pop could contain around a hundred and fifty food calories. Caffeine and sugar could bring about dehydration. Sugary pop does in no way assist people sticking to an appropriate weight loss system. Given that a body tends to be primarily made up of water possibly then this liquid will be a proper choice. In addition, this beverage helps with an ideal healthy weight loss diet via keeping metabolism raised.
You may also enjoy diet plan, weight loss diet and best weight loss.
Help physicians fill in the missing information when they use visual cues to determine a diagnosis. Most coders are familiar with the coding and documentation guidelines required to support the management of hierarchical condition categories (HCCs); for certain conditions, however, physicians may use visual cues to decide whether the patient’s diagnosis is appropriate. This can […]
AAPC Knowledge Center
Cystic fibrosis (CF) is a common hereditary disease (genetic based disease) that affects the mucus producing tissues of the body. Many systems of the body rely on fully functioning mucus glands and when they do not work well, many medical complications can arise.
Cystic fibrosis symptoms are caused by heavy, thick, mucus. They include frequent coughing that brings up thick discolored mucus and frequent bouts of chest congestion that often leads to pneumonia. The skin may taste salty and sufferers are easily dehydrated.
The stools of a CF patient are thick, greasy, and smell foul. The patient may be eating well and have a good appetite, but fails to gain weight and thrive. Stomach pain, bloating and excessive gas is caused by too much gas in the intestines and is painful.
There are other medical problems caused by cystic fibrosis. Infertility in men is often caused by this disease. Sinusitis is caused when the space behind the eyes, nose, and forehead are being blocked by thick mucus. Nasal tissues under these condition become infected and cause sinusitis when the lining of the sinuses becomes blocked. This is very common in patients with CF. Nasal polyps may also develop in the sinuses and require surgery to remove.
Cystic fibrosis affects the lungs and bronchial tubes. The bronchial tubes are the large airways in your lungs. Bronchiectasis is a lung disease that causes these airways to become stretched and flabby. They produce pockets where mucus collects. These pockets are a breeding ground for bacteria and infection causes more damage to the bronchial tubes. This can lead to further bronchial infections and serious illness including respiratory failure.
If your lungs are not moving enough oxygen through the body, “clubbing” can be a result. Clubbing is the widening and thickening of the toes and fingers. Clubbing is a definitive sign of CF, if the condition has not already been diagnosed.
Other serious illnesses and complications include liver disease, diabetes, gallstones, collapsed lungs, and rectal prolapse. Extensive coughing and the body having problems passing stools cause rectal prolapse. This pushes the rectal tissue outside of the body.
Another serious illness that may occur because of this genetic disease is low bone density. The body does not get enough Vitamin D and this can cause rickets. Your doctor may recommend Vitamin D supplements to prevent low bone density.
Since there is currently no cure for cystic fibrosis, medical treatment is focused on treating the various symptoms and medical problems that spring up from having CF.
Scott Harker is the publisher of several health related websites… To find out more about Cystic Fibrosis, please visit Cystic Fibrosis Articles For reviews of some of the best books about cystic fibrosis, please visit Cystic Fibrosis Books
Related Medical Coding Articles