A 55-year-old female patient returns to the office with complaints of gout pain. She is complaining of swelling and a burning pain in her left toe. She has been taking an over-the-counter NSAID to treat the pain, but this has done little to alleviate it. This is her second flare this year. The patient denies…
ICD-10 2.0: An Evolving Data Set
One year after the official go-live of the International Classification of Diseases, 10th revision (ICD-10), the coding language is scheduled to undergo an evolution, with nearly 1,975 additions, more than 300 deletions and 425 revisions. This brings the total set of diagnosis codes to more than 71,480. The new and revised clinical modification codes (ICD-10-CM)…
How to Document E/M Services
Documenting evaluation and management (E/M) services involves many factors, and it’s important to code to the most appropriate level of service to avoid compliance risks. To assist providers with documentation, the Centers for Medicare & Medicaid Services (CMS) provides its 1995 and 1997 Documentation Guidelines for Evaluation and Management Services. For billing purposes, either version…
Hours Spent Record Keeping May Fuel Physician Burnout
(Reuters Health)—For every hour doctors spend treating patients during a typical workday, they devote nearly two more hours to maintaining electronic health records (EHR) and clerical work, a small U.S. study suggests. Time spent in meaningful interactions with patients is a powerful driver of physician career satisfaction, but increased paperwork and time on the computer…
Rheumatology Coding Corner Answer: Level 4 New Patient Visit
Take the challenge. Correct Answer: CPT: 99204 ICD-10: I73.00 Coding Rationale This is a new patient, outpatient visit for a self-referred patient. There is no formal consultation request from another physician; therefore, the encounter does not meet criteria for a consultation. This encounter is coded as 99204 because it included: Comprehensive history—Extended history of the…
Rheumatology Coding Corner Question: Level 4 New Patient Visit
A 32-year-old female patient comes in for an initial visit. She is self-referred and complains of pain, numbness and color changes in her fingers when exposed to cold. The patient reports that her right distal index finger, left distal index finger and fourth right finger turn white and blue with pain and numbness when exposed…
Transition to ICD-10 Diagnostic Code Set Successful for Most Rheumatology Practices
It has been 11 months since the implementation of the ICD-10 diagnostic code set on Oct. 1, 2015, a change from the previous ICD-9. Most practices can probably attest that the transition came and went without the predicted doomsday outcome: Claims were still processed, the confused alphanumeric coding was applied, and patients were not deprived…
End of the Road: ICD-10 Grace Period Expires in October
The final milestone on the road to implementing ICD-10 (International Classification of Diseases, 10th revision) is drawing near. The 12-month grace period is scheduled to end as of Oct. 1, 2016, but that date will most likely pass with little notice, because implementation appears to have gone well since Oct. 1, 2015. “On average, it…
Rheumatology Coding Answer: Level 3 Established Patient Evaluation and Management Office Visit
Take the challenge. CPT: 99213 Diagnosis Codes: M05.79, M17.12, Z79.1, Z79.899 Rationale to code this encounter as 99213: History—The history of present illness was extended. The review of systems was comprehensive, and two of the three past, family and social history were documented. This makes the history level comprehensive. Eight systems were examined. This makes…
Rheumatology Coding Question: Level 3 Established Patient Evaluation and Management Office Visit
Level 3 Established Patient E&M Visit A 43-year-old patient is seen in the office for a follow-up visit of her RF-positive rheumatoid arthritis and primary osteoarthritis of the left knee. The patient is on sulindac, methotrexate and folic acid. At her last visit, the patient’s methotrexate dose was increased, which has greatly reduced her pain….
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