Can you help us with a coding issue regarding spontaneous abortions?  We are wondering if it is appropriate to code a delivery code is they say the fetus was delivered.  The patient came into the hospital actively having a miscarriage, “She delivered the second trimester fetus, approximately 16 weeks”.  Placenta was manually removed by the […]

One of the coders posed a question to me about the use of the 338 codes for our Pain Management Clinic.  We are not getting documentation from the physician that pain is acute or chronic.  He gives the diagnosis of the 700 codes (721.0, 722.0, 723.0, 723.1, and 723.4).  The coder wants to query the […]

A biller from the other office which Dr. A works for tells me that a physician discharge code has to be used and it has to be a face to face. Since rehab physicians are not required to see patients on the day of discharge, this makes no sense. I suggested that Dr. A just […]

The coders are telling me that they cannot use a comorbid condition that is only documented by a physician consultant and not by our rehab doctors.  Specifically, a cardiologist stated in 2 of his progress notes that the patient had “acute on chronic CHF” but the rehab doctors did not mention it, therefore the coders […]

I have a question about the order we are billing the caths, etc~ for example if we bill 93458-26, 59 and 92928 The RVU is actually higher on 92928 since we are using the -26 modifier on the cath… should we be reversing the order to   92928 and 93458-26,59   ? I am asking since […]

I remember that you explained the difference between tracheostomy status and attention to tracheostomy. Can you please clarify the difference between the two so that I can make sure I am correct          (Anonymous) V44.0 is tracheostomy status – Artificial Opening Status (without need for care per the ICD manual). V55.0 is attention to trach: – Attention to […]