Is anyone aware of any Medicare benchmarks for the proportion of complex repairs to intermediate repairs (like the way they benchmark the proportion of each E/M visit a provider does)?
Thanks!
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Tag Archives: Versus
NP versus XRAY
So, I am new to an Orthopaedic Surgeons office and OMG is there a lot to learn!! Lets start with a basic, patient comes into the office on the 10th, never seen before and just gets an xray, then comes back on the 12th and sees the provider for the first time, new or not new patient? Keep in mind that xray will be billed under the same tax id as the provider, 2 days prior to the patient actually seeing the provider. Thank you in advance!
99213 versus 99214
I always feel stressed when we have a new provider come on board with our facility and we have differences on E/Ms. In this case the provider coded this visit as 99214. I down coded it to a 99213 based on the following (follow up on one problem worsening or not responding to treatment, HPI, and time spent with patient). I do thing the MDM is Moderate but I am not sure that trumps everything else? I would appreciate your opinions!
75 year old female who is 1.5 weeks post-op from aortic valve replacement (TAVR), with history of peripheral neuropathy, multiple spinal surgeries, Addison’s disease, atrial fibrillation s/p AICD/pacemaker on warfarin, CAD here for left leg pain and increased swelling.
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Leg swelling.
– INR 1.3
-no lightheadedness/dizziness
– has had palpitations the last few days; had them most recently this am.
-feels like she is getting adequate air; no shortness of breath
-no chest pain
-left leg swelling from knee down worse than usual
-new pain in her calf that is different from her neuropathic pain.
-neuropathy in both feet, unable to tell whether there is pain or tingling
– no history of DVT or PE that she can recall.
– she does not believe that she was on heparin or lovenox in hospital. She is very worried about an allergic reaction if she were to start a new medication today.
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Dr. Siwek’s note says: "Coumadin was started for possible valve leaflet thrombosis. Did not improve gradient – hence TAVR. Probably not unreasonable to continue initially post TAVR but indication/duration a little unclear."
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Review of Systems
Constitutional: Negative for chills and fever.
Respiratory: Negative for cough, shortness of breath and wheezing.
Cardiovascular: Positive for palpitations and leg swelling (left leg). Negative for chest pain, orthopnea and PND.
Gastrointestinal: Positive for nausea. Negative for constipation, diarrhea and vomiting.
Genitourinary: Negative for dysuria and urgency.
Skin: Negative for rash.
Neurological: Negative for dizziness and headaches.
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Patient Active Problem List
Diagnosis
Chronic adrenal insufficiency (HCC-CMS)
GERD (gastroesophageal reflux disease)
Vaginal prolapse
Psoriasis
Atrial fibrillation (HCC-CMS)
Pacemaker
Breast cancer screening
Pernicious anemia
Mitral valve insufficiency and aortic valve insufficiency
Mixed hyperlipidemia
Peripheral vascular disease, unspecified (HCC-CMS)
Coronary artery disease with angina pectoris with documented spasm (HCC-CMS)
Colon cancer screening
Essential hypertension
Controlled substance agreement signed, pending scanned documents
Fusion of spine of thoracolumbar, multilevel fixation screws, hx revision fo broken hardware
Other osteoporosis without current pathological fracture
Chronic obstructive pulmonary disease (HCC)
Proctitis
Gout
Allergic rhinitis
Chronic pain of multiple sites
Hypertrophic cardiomyopathy (HCC-CMS)
Chronic pain of right knee
Opioid dependence on agonist therapy (HCC-CMS)
Pulmonary hypertension (HCC-CMS)
Ulcer of great toe (HCC-CMS)
Physician orders for life-sustaining treatment (POLST) form indicates patient wish for full code resuscitation status
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Past*Medical*History
Past Medical History:
Diagnosis Date
Addison disease (HCC-CMS) *
Asthma *
Cataract *
DJD (degenerative joint disease) *
Fibromyalgia *
GERD (gastroesophageal reflux disease) *
HTN (hypertension) *
Hypercholesterolemia *
Mammary dysplasia *
Pap smear 12-29-05
* normal
Psoriasis *
PUD (peptic ulcer disease) *
PVD (peripheral vascular disease) (HCC-CMS) *
Rhinitis, allergic *
Tobacco use disorder *
Vaginal prolapse *
Valvular heart disease 8/29/2015
* 11/2012 s/p tissue mitral and aortic valve replacement b Dr Siwek. Severe MR with hypertrophic cardiomyopathy, mild aortic stenosis.
*
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Past*Surgical*History
Past Surgical History:
Procedure Laterality Date
APPENDECTOMY; * *
ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING, ARTICULAR CARTILAGE (CHONDROPLASTY) * *
* benign bone tumer removed
COLONOSCOPY * 10-29-12
* Dr.Rose
COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DX, W/WO SPECIMENS/COLON DECOMP (SEP PROC) * 7/28/16
* Colonoscopy
CORONARY ART/GRFT ANGIO S&I * 8/4/15
* Coronary cath/angio
DOPPLER ECHOCARDIOGRAPHY; COMPLETE * 7/2016
* LVEF low normal, 50-55%. Pacer/defibrillator present, bioprosthetic MV present and appears to be functioning normally. Trace MR, mild TR. PA pressure 47mmHg. Bioprosthetic aortic valve appears to be functioning normally.
EMBOLECTOMY/THROMBECTOMY; FEMOROPOPLITEAL/AORTOILIAC ARTERY, LEG INCISION * 6/30/15
* Left common & deep femoral artery thrombectomy, left iliofemoral embolectomy, patch angioplasty of left common & deep femoral artery placment of left external iliac artery, Left 6/30/15
EXTREMITY STUDY * 8/4/15
* Left LE US negative for DVT
FEM/POPL REVAS W/ATHER * *
HEMIARTHROPLASTY, HIP, PARTIAL * *
* L total hip followed by reattachment of muscle following surgery
LAMINECTOMY, W/O FACETECTOMY/FORAMINOTOMY/DISKECTOMY, 1/2 SEGMENTS; LUMBAR * *
* Laminectomy, Lumbar 13 back surgeries
NEUROPLASTY &/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL * *
* bilateral carpal tunnel
OOPHORECTOMY, PARTIAL/TOTAL, UNILAT/BILAT * *
* bilateral
REPAIR ARTERIAL BLOCKAGE * 11/11/15
* SUCCESSFUL PTA OF L COMMON FEMORAL ARTERY WITH DRUG COATED BALLOON
UNLISTED PROC, FOOT/TOES * *
* toe surgery by Dr. Clarke after shovel injured her toe.
UNLISTED PROC, LEG/ANKLE * *
* "ankle surgery"
UNLISTED PROC, SPINE * *
* thoracolumbar fixation hardware
VAGINAL HYSTERECTOMY, UTERUS >250 GMS; * *
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Social*History
Social History
*
Social History
Marital status: Single
* * Spouse name: N/A
Number of children: 5
Years of education: 14
*
Occupational History
Not on file.
*
Social History Main Topics
Smoking status: Former Smoker
* * Quit date: 12/11/2008
Smokeless tobacco: Never Used
Alcohol use No
Drug use: No
Sexual activity: Not on file
*
Other Topics Concern
Not on file
*
Social History Narrative
* Lives alone, her daughter lives a block from her
*
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Current Outpatient Prescriptions
Medication Sig Dispense Refill
metoclopramide HCl (REGLAN) 10 mg tablet Take 1 Tab by mouth 4 (four) times daily before meals and nightly 120 Tab 3
polymyxin B sulf-trimethoprim (POLYTRIM) 10,000 unit- 1 mg/mL ophthalmic solution Place 1 Drop into the right eye 4 (four) times daily 10 mL 0
promethazine (PHENERGAN) 25 mg tablet TAKE 1 TABLET BY MOUTH EVERY 8 HOURS AS NEEDED FOR NAUSEA. 30 Tab 0
promethazine (PHENERGAN) 25 mg tablet TAKE 1 TABLET BY MOUTH EVERY 8 (EIGHT) HOURS AS NEEDED FOR NAUSEA 30 Tab 5
buprenorphine-naloxone (SUBOXONE) 8-2 mg SL tablet DISSOLVE 1/2 TABLET UNDER THE TONGUE 3 TIMES A DAY. 42 Tab 0
predniSONE (DELTASONE) 5 mg tablet Take 2 Tabs by mouth once daily 90 Tab 3
ondansetron HCl (ZOFRAN) 4 mg tablet TAKE 1 TABLET BY MOUTH EVERY 4 HOURS AS NEEDED FOR NAUSEA. 60 Tab 3
allopurinol (ZYLOPRIM) 300 mg tablet Take 1 Tab by mouth once daily 30 Tab 5
gabapentin (NEURONTIN) 600 mg tablet Take 1 Tab by mouth 2 (two) times daily 180 Tab 6
ergocalciferol, vitamin D2, (VITAMIN D2) 50,000 unit capsule Take 1 Cap by mouth once a week 12 Cap 3
PNV,calcium 72-iron-folic acid 27 mg iron- 1 mg tab Take 1 Tab by mouth once daily * *
fluticasone (FLONASE) 50 mcg/actuation nasal spray Place 2 Sprays into the nostril(s) once daily 16 g 11
carvedilol (COREG) 6.25 mg tablet Take 1 Tab by mouth 2 (two) times daily with a meal * *
alirocumab 75 mg/mL pnij Inject 75 mg into the skin every 14 (fourteen) days. * *
cyclobenzaprine (FLEXERIL) 10 mg tablet TAKE ONE TABLET BY MOUTH THREE TIMES DAILY AS NEEDED FOR MUSCLE SPASMS 30 Tab 5
meclizine (BONINE) 25 mg tablet Take 25 mg by mouth 2 (two) times daily as needed. * *
ENTERIC COATED ASPIRIN 81 MG TAB, DELAYED RELEASE 1T PO QD 30 Tab 11
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No current facility-administered medications for this visit.
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Objective
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Vitals
Vitals:
* 09/17/18 1000
BP: 134/65
Pulse: 79
Resp: 16
Temp: 97.8 °F (36.6 °C)
TempSrc: Oral
SpO2: 95%
Weight: 139 lb (63 kg)
Height: 5′ 1" (1.549 m)
Last 3 Vitals
Office Visit from 9/17/2018 in Winding Waters Medical Clinic Office Visit from 9/13/2018 in WW JOSEPH MEDICAL CLINIC Office Visit from 8/16/2018 in WW JOSEPH MEDICAL CLINIC
Temp 97.8 °F (36.6 °C) 97.8 °F (36.6 °C) 97.5 °F (36.4 °C)
Pulse 79 85 85
BP 134/65 106/56 115/73
Resp 16 16 20
Weight 139 lb (63 kg) 141 lb (64 kg) 139 lb (63 kg)
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Estimated body mass index is 26.26 kg/m² as calculated from the following:
Height as of this encounter: 5′ 1" (1.549 m).
Weight as of this encounter: 139 lb (63 kg).
Facility age limit for growth percentiles is 20 years.
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Physical Exam
Constitutional: She is oriented to person, place, and time. No distress.
Pale elderly female
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Neck: Normal range of motion. Neck supple. No thyromegaly present.
Cardiovascular: Normal rate and regular rhythm.
No murmur heard.
2+ femoral pulses bilaterally. Unable to palpate DP or tibialis posterior pulses
Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress.
Abdominal: Bowel sounds are normal. She exhibits no distension and no mass. There is no tenderness.
Musculoskeletal: She exhibits edema.
1+ pitting pedal edema bilaterally
Lymphadenopathy:
She has no cervical adenopathy.
Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit.
Skin: Skin is warm and dry. She is not diaphoretic. No pallor.
Psychiatric: She has a normal mood and affect. Her behavior is normal.
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Assessment and Plan: 75 year old female who is 1.5 weeks post-op from aortic valve replacement (TAVR), with history of multiple spinal surgeries, Addison’s disease, atrial fibrillation s/p AICD/pacemaker on warfarin, CAD here for left leg pain and increased swelling. Given recent surgery and subtherapeutic INR, there is concern for DVT/PE. However, patient’s leg swelling is relatively unimpressive with no erythema, warmth, collateral veins or significant enlargement compared to other side. I reviewed discharge summary and records from her recent hospitalization. Per her thoracic surgeon, unclear benefit of warfarin in this situation, and duration of therapy also unclear. No shortness of breath now and VS are within normal limits, making pulmonary embolism less likely, but she has had palpitations last 2 days. Other etiologies of palpitations could be cardiac arrhythmia such as rapid atrial fibrillation, dehydration, anxiety. None of these are apparent today.
– LLE duplex now.
– shared decision making around CTPA – patient declines at this time and I think this is reasonable – see above.
– will rx lovenox if US shows DVT.
– strict return precautions given – see instructions.
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R60.0 Edema of left lower extremity (primary encounter diagnosis)
Plan : US STUDY FOLLOW-UP (SPECIFY) (Future)
US STUDY FOLLOW-UP (SPECIFY)
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I48.91 Atrial fibrillation, unspecified type (HCC-CMS)
Plan : INR COAGUCHEK (POCT)
INR 1.3 today. Plan to increase warfarin dosing to 10 mg on Monday and Friday and 5 mg the rest of the week. Recheck Friday 9/21/2018
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M79.605 Left leg pain
Likely explained by peripheral neuropathy. Continue gabapentin. Will monitor.
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Total of 20 minutes was spent with the patient. Greater than 50% of time was spent in FTF counseling and coordination of care for the above diagnoses.
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Responsibilities of the billing company versus the office
If you have worked with or for a billing company, can you please advise who should be responsible for the following tasks – the office or the billing company?
1. Researching and correcting patient’s insurance when claims are denied due to wrong insurance or incorrect policy number.
2. Finding and fixing patient addresses when statements are returned due to data entry mistakes or unforwardable mail.
Thank you!
GI versus Abdomen using 95 Guidelines
I’m confused as to what elements GI needs to have to count it as an organ system versus a body area using 95 Guidelines. We are being told that this system/area only counts as GI if states bowel sounds. If the provider doesn’t document bowel sounds, we have to count it as a body area and not the organ system.
Example
General: Pleasant, NAD, sitting in a chair
HEENT: EOMI; no scleral icterus; MMM
Lungs: decreased breath sounds
CV: RRR,
GI: soft, NT/ND; no guarding or rebound
Extremities: WWP, No LE edema
Neuro: AAOx3; no asterixis
Skin: warm; no jaundice
Psych: Normal mood/affect
According to what we are being told, GI would not be counted as a system but rather a body area. Help would be greatly appreciated. Thanks
Billing versus ordering physician
Our administrator approached me earlier this week with this scenario:
"We are wanting to go from our assigned provider days to doctor of record". I hope I can explain this well enough…. Currently we have two physicians (three in a few weeks), and they have providing doctor days (i.e. one has T/TH and the other M/F and they alternate W). The administration came to me and said, "WE want to go from providing doctor days to doctor of record" meaning, "our docs want to write orders and be the billing doctor of record for their patients". My dilemma is… administration wants ME to find where a physician can write an order on their patient and have it be standing until their procedure takes place. I work in a facility where patients are monitored several times a week/month before a procedure takes place. Often times the provider/ordering physician is NOT in the office due to illness, performing surgery elsewhere, or vacation. HOW would it be possible for a physician to write an order, have another physician change/update a treatment plan, and the ordering physician STILL get credit for the services billed?
Ethically, I am having a HUGE problem with this scenario! Where can I find information to state that a physician cannot write an ongoing order on a patient if a different physician reads, changes, or alters a care plan? I have looked on CMS and OIG, but perhaps my searches are to vague, because I am not finding what I am looking for.
ANY suggestions would help me and my comfort level!!!!
So…. EXAMPLE: can a provider write an order on their patient, leave for vacation, and have another physician give a treatment plan and it be billed under the ordering physician? Patient X came in for ultrasound and lab work today and it was determined by NOT ordering physician to increase Drug A and add Drug B to their protocol and return to the clinic on day 5? Can ORDERING provider get credit/bill for this case?
Thank you! My ethics are holding firm!
Michelle
Low Complexity versus Moderate Complexity
I just finished a practice exam from AAPC and I would appreciate a bit more clarification on the answer if possible!
If the physician documented a detailed history, comprehensive examination and a medical decision making of moderate complexity, how is the correct E/M code 99221 when the description states low complexity? Is low and moderate interchangeable? I thought the correct code would be 99222.
When to assign Z71.1 versus Z03.89?
Hello,
Is there any reference material that someone can share as to when will it be appropriate to assign Z71.1 (Worried well) versus Z03.89 (Encounter for observation for other suspected diseases and conditions ruled out)?
Is Z03.89 specific to observation services only? I would like to see how others use these codes.
Any insight would be greatly appreciated. Have a great day!
New Problem to examining MD: Additional Work-up versus No Additional Work-up
Hi! I am a new CPC-A working on the Practicode. I am using the E/M Audit Tool to assign points for MDM. I am also using tools from E/M University. A lot of the cases I am working through are in the ED. I am missing the mark on leveling – I just coded 2 practice cases in a row that I should have coded 99285, but I thought they were 4s. If the examining doctor is discharging a patient because they are stable but advising them to make the next available appointment with a specialist or other physician, is this considered a New Problem with Additional Work Up Planned since the physician is counseling them to see another physician? I thought it was No Additional Work up Planned because the patient was being discharged. Thanks in advance. E/M leveling is a learning process for me :).
MDM – Major versus Minor surgery, identified risk factors
Medicare patient presents for consult with general surgeon – History of colon polyps and need for screening colonoscopy
Problems – 1 Hx of colon polyps
Data – 0
Risk – Decision to proceed with screening colonoscopy
Problems – 1 Hx of colon polyps
Data – 0
Risk – Decision to proceed with screening colonoscopy
PMH includes – Prostate hypertrophy, HTN, and type 2 diabetes, but none of these conditions is specifically identified as a risk factor for surgery, just listed in the PMH.
Is this a minor surgery (per CMS definition global period 0 days 45378), a minor surgery with identified risk factors since the additional conditions are listed in the PMH, or a major surgery with/without identified risk factors.
Is there any reference where I could find direction on how to determine minor versus major surgery for MDM?
In order to be considered identified risk factors does the physician have to document a possible negative impact on the proposed surgical procedure or is it enough to simply list the conditions in the medical history?
Thank you in advance. Any input is greatly appreciated.
Angela