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Tag Archives: Results

Novitas Posts TPE Results for PT and OT

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Round 1 of Novitas Solutions’ targeted probe and educate (TPE) review for outpatient physical and occupational therapy (CPT® codes 97010-97546) indicates there is room for improvement in getting claims paid. TPE Results Are In The Medicare Administrative Contractor’s (MAC) TPE round 1 results for CPT® 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic […]

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Q&A: Coding from ED documentation and test results

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Q: Can you code strictly from emergency department (ED) documentation? Can you code from test results and imaging (radiologist reports)?
 
A: Coders can assign diagnosis codes based on documentation of any licensed independent provider that provides direct care to the patient. This includes physicians, nurse practitioners, and physician assistants who provide care to the patient during this encounter. Thus, the documentation of ED physicians or other providers (nurse practitioners and physician assistants) can be used to assign a code.
 
This comes with two notes of caution, however. First, this documentation must not conflict with the attending physician. If the documentation conflicts, then query for clarification. Second, if the ED physician documents a diagnosis, but you see no evidence of treatment or monitoring continued through the inpatient stay, query for the significance of the diagnosis.
 
As for the second piece of your question, diagnosis codes cannot be assigned based on test results or imaging. The documentation of radiologists and pathologists cannot be used to assign diagnosis codes, as such physicians do not provide direct patient care. Coders or clinical documentation improvement (CDI) specialists would need to query the attending provider to assign the appropriate diagnosis code.
 
Coding Clinic for ICD-10-CM/PCS has published guidance regarding the use of such reports to further specify the location of a fracture or cerebrovascular accident from imaging. But we first must have the diagnosis as documented by the attending physician or provider responsible for the direct care of the patient.
 
Editor’s note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer, and CDI education specialist at HCPro, a division of BLR, in Danvers, Massachusetts, answered this question on the ACDIS website. Contact her at [email protected].
 
This answer was provided based on limited information submitted to JustCoding. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.

 

Need expert coding advice? Submit your question to editor Steven Andrews at [email protected] and we’ll do our best to get an answer for you.

HCPro.com – JustCoding News: Inpatient

MIPS 2017: The Results Are In!

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Of the 1,057,824 clinicians eligible to participate in the Merit-based Incentive Payment System (MIPS) in the inaugural year, 1,006,319 (95 percent) participated in MIPS and avoided a negative payment adjustment, according to the Centers for Medicare & Medicaid Services’ (CMS) 2017 Quality Payment Program (QPP) Experience Report. The report, which CMS released March 21, provides […]

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Billing an E/M when patients come in to review testing results

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Is it acceptable to bill an E/M level of service when a patient comes in to discuss/review testing that was done? Should an E/M level 99211 be appropriate for billing, or should the visit be coded based on time spent counseling the patient? Currently, the provider is billing an established patient level of service, usually a 99213 or 99214. The provider documents a History, Exam, and MDM.

Any thoughts?

Thanks,
Cheryl

Medical Billing and Coding Forum

Can you bill for UA done in office with only documentation being the results?

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A patient came in to PCP’s office to do a urine sample- the MA did a urine dip. They billed for 81002 but I do not have documentation by a nurse or doc indicating the patient was here…. I know the patient was because the results are in chart. My question is are the urine results proper documentation to support billing 81002? At my previous practice the MA always did a note with why patient coming in for urine sample and what physician was in the office…etc. and included the results. Newer to auditing and needing some advice. Thank you!

Medical Billing and Coding Forum

Help with applying codes to test results

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Hello!!

Admittedly, Im a rookie at coding audiology. I need help in applying the CPT codes to the test results to insure the correct codes are applied. For example: audiology.jpg Are both of the images applicable to 92567?

Any help is appreciated!!

Attached Images

Medical Billing and Coding Forum