You Be the Coder: June

38 year old Female presented to the office for scheduled Essure sterilization. Patient identified, local anesthesia administered and the patient was placed in dorsal recumbent position. The physician uses a speculum to open the cervix and then places the hysteroscope...

Coding for Cardiac Catheterization

Cardiac catheterization is a diagnostic test to examine the heart or coronary vessels or both. There are two sets of codes differentiated by examination for congenital and all other conditions. The corresponding “code map” demonstrates correct coding for noncongenital...

History of Present Illness: Severity

Severity is a statement or a rating of intensity (0-10) from the patient that indicates the degree or measurement of how bad the chief complaint is. This rating not only is documented based on 0-10 scale, but it can be captured using phrases such as: worsening,...

Template to Fulfill Home Health Requirements

Open door forums are being held to discuss the use of a template to aid in fulfilling the face-to-face requirement for Medicare beneficiaries receiving home health care. “In fiscal year (FY) 2014, the Comprehensive Error Rate Testing (CERT) program found that more...