Q: What are some times when it might be acceptable for a provider to copy and paste medical information into an electronic health record and when is it absolutely not acceptable?
Q: Our team had a recent case that involved a small midline episiotomy which extended to a second-degree laceration which was repaired with 3-0 vicryl rapide sutures. Would we code the episiotomy and repair or just the repair, and why?
Q: What are the applicable modifiers that can be used when a test fails for medical necessity or if an Advance Beneficiary Notice (ABN) has been signed?
Q: Is CPT code 96416 (chemotherapy administration requiring use of portable pump) the same as HCPCS code G0498 (initiation of infusion of chemotherapy in office using portable pump)? Our facility is trying to determine if it would be appropriate to set up G0498 as a Medicare override for 96416.
Q: At my institution, all of our congestive heart failure exacerbations get at least one chest x-ray. Is that enough “diagnostic testing” to code the secondary condition in accordance to Coding Clinic ?
Q: For a ureteroscopy intended as a procedure with a biopsy and double-J stent, if the procedure ends when only the scope was placed before a biopsy was taken, could you just code ureteroscopy instead of coding it with the biopsy and the modifier-74 (discontinued outpatient hospital/ambulatory surgery center procedure after administration of anesthesia)?
Q: I can't distinguish between "code first" and "in diseases classified elsewhere.” Both are used with manifestations and both can't be sequenced as principal diagnosis and both need etiology codes, so what is the difference?
Q: We use an electronic system at our hospital, and find it is difficult to query a physician since we all have our own processes. Would you recommend having a set format for a query that is used electronically?
Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.
Q: What are the documentation requirements for a continuous infusion for an observation patient, especially spanning the midnight hour? We often see rate change or rate verification notations during continuously running infusions, but would a start and stop time be required or expected for each bag change?
Q: We are currently coding a chart for an acute kidney injury which has the baseline serum creatinine and urine output missing from the chart. Is there something we can do before we have to query the physician?
Q: When reporting multiple separate infusions of the same substance or drug provided through the same IV site during one visit, should we add up the total time and then report the appropriate codes?
