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Tag Archives: workup

Additional Work-up and MDM question.

Posted on by
Need opinion on the following Assessment and Plan:

1. Strain of supraspinatus muscle
S46.012D: Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter
PHYSICAL THERAPY SHOULDER REFERRAL – Schedule Within: provider’s discretion

2. Strain of subscapularis muscle
S46.012D: Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter

3. Chronic kidney disease due to type 2 diabetes mellitus
E11.22: Type 2 diabetes mellitus with diabetic chronic kidney disease
GLYCOHEMOGLOBIN, TOTAL, BLOOD – To be performed on or around 12/08/2018
BMP, BLOOD – To be performed on or around 12/08/2018
LIPID PANEL, SERUM – To be performed on or around 12/08/2018

4. Hypothyroidism –

E03.9: Hypothyroidism, unspecified
levothyroxine 137 mcg tablet – TAKE 1 TAB DAILY MONDAY-SATURDAY, 1/2 TAB SUNDAY Qty: 28 tablet(s) Refills: 1 Pharmacy: CVS/PHARMACY #6510
TSH, SERUM OR PLASMA – To be performed on or around 12/08/2018

Discussion Notes
Will refer to PT and have Pt f/u in the next month. Informed her that an injection was not appropriate this close to the last and would likely not help as she has more than one tendonopathy. Pt given lab order which should be completed the week prior to her next visit.

I am going back and forth as far as counting the Chronic Kidney disease due to type 2 diabetes mellitus and the Hypothyroidism for the Medical Decision Making. There is no HPI relating to either of these diagnoses. Patient came in for the shoulder issue and that is all that is addressed in the History and Exam. It appears the provider ordered the lab work so he would have it for the patient’s future visit, and possibly the patient needed a refill on medication. I know I need to query the provider, as need to know the status of each of these diagnoses. However, if the sole purpose was ordering the lab work, do I even need to consider these two diagnoses in the MDM?

Thanks, in advance, for your assistance.

Medical Billing and Coding Forum

Hospital Discharge workup prior to the actual discharge date

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Hello,

I need some clarification on the scenario below. Please help!

On 08/02/2018, Ms. G was admitted to the hospital. On 8/04/2018, Dr. X examined the patient and found she was stable and ready to be discharged. Dr. X discussed the discharge to a nursing home with Ms. G and she agreed. Dr. X created the Discharge Summary and coded the encounter as a Discharge. There was a transportation issue with the nursing home and Ms. G ended up staying inpatient for another night.

On 8/05/2018, Dr. K was doing rounds at the hospital and examined Ms. G. She was still stable and agreed to be discharged. Dr. K created a Progress Note and coded a subsequent inpatient code.

Both physicians are Internal Med. specialists.

My questions are:
Can the discharge summary be created prior to the actual discharge date, causing the date of service to be different then the actual discharge date?
Can a subsequent inpatient code (99231-99233) be billed after the discharge code (99238) was billed? If not, what should be billed?

Thank you for your help!

Medical Billing and Coding Forum

New Problem to examining MD: Additional Work-up versus No Additional Work-up

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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 :).

Medical Billing and Coding Forum

New patient with workup

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Is this considered new patient with work up or not? New patient comes to clinic for elevated psa. The doctor gives the options of moving on to an MRI of the prostate to determine if they are any lesions and if so then doing a biopsy or just move on to the biopsy. The patient chooses to do the MRI first. Does this count as New patient with work up? Or since the patient already has the dx of elevated psa that it would just be a new problem without work up.

(hope this makes sense)

Medical Billing and Coding Forum

Billing RN workup ?

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Our physicians are looking at having RNs do new patient or new problems for existing patients, prior to being seem by a physician or NP. They say that many/most OB practices are doing this now, since the service is not billable anyway (ie for a new OB). Can anyone clarify how (or if) this would be billed ? I am believing it would not be billable since it would likely be a same day visit (RN work-up then MD/ NP comes in)

Thanks !

Medical Billing and Coding Forum

CPT code for lymphoma workup needle core biopsy vs biopsy

Posted on by
Good Morning All!
A question was brought up by one of our pathologists concerning lymphoma workups for needle core biopsies vs biopsy – We have been upcoding lymph node biopsies for lymphoma work ups to an 88307 but for the needle core biopsies, we have been keeping them as an 88305. The pathologist looked through Paget’s and couldn’t find any reasoning as to why we should keep a needle core to a 305 – I have included the email for better clarity – Anyone have any thoughts on this?

"Do you recall the reasoning for that? From my reading, I believe we should code 88307 for lymphoma work-up any time flow is done on the same node and/or IHC (to evaluate for a lymphoma) is done – both of which were done on this specimen. I didn’t see anything in the coding services handbook that would indicate whether it is a core biopsy vs excisional biopsy would make any difference.

The extra work that must be documented will include
at least one of the following: touch preparation or frozen section to assess specimen adequacy
and determine what, if any, special studies are appropriate; H&E sections beyond the number
typically associated with a lymph node biopsy; flow cytometry immunophenotyping; molecular
pathology; and/or immunohistochemistry."

Medical Billing and Coding Forum