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You Be The Coder: Halloween Edition

Assess your knowledge of Evaluation and Management while taking our free E/M Calculator for a test drive! Review the below patient notes and plug the appropriate information into our audit tool. History of Present Illness (HPI) A 12 year old female patient is experiencing auditory hallucinations, severe head pain, and is presenting with abnormal posture. …

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You Be The Coder: Evaluation and Management (E/M)

Assess your knowledge of Evaluation and Management while taking our free E/M Calculator for a test drive! Review the below patient notes and plug the appropriate information into our audit tool. History of Present Illness (HPI) Patient is complaining of chest pain which he has been experiencing on and off for two days now. He…

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You Be The Coder: October

Can you identify what these medical abbreviations stand for? DOE ICP LBW NST PUD PWB AFB LUE NVD PAT Answers:  Dypsnea on Exertion Intra Cranial Pressure Low Birth Weight Non Stress Test Peptic Ulcer Disease Partial Weight Bearing Acid Fast Bacilli Left Upper Extremity Nausea, Vomiting, Diarrhea Paroxysmal Atrial Tachycardia

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You Be The Coder: September

How many physical examination elements can you extract from this documentation? VS: 124/80, Pulse: 74, Weight: 174 pounds CTA A&Ox3 No CCE Answer below:   Answer: Six Constitutional – Vital Signs Respiratory – Clear to Auscultation (CTA) Psych – Alert and Oriented X 3 (A&Ox3). No CCE; (Clubbing, Cyanosis, Edema) Musculoskeletal (Clubbing) Cyanosis (Skin) Edema…

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You Be The Coder: August

What would the correct CPT code assignment be for this scenario? A male patient, 54 years of age, comes in on May 3, 2014 for a scheduled transurethral resection of the prostate (TURP). The patient had an initial TURP back in August 2012 but is still experiencing difficulty voiding. A. 52601 B. 52648 C. 52630…

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You Be the Coder: July

Test your knowledge The Advanced Beneficiary Notice of Non-coverage (ABN)  A 67 year old Medicare patient comes into the office for a cosmetic skin procedure. The following day the billing office staff checked and found the reason for service was not medically reasonable as per the Local Coverage Determination. The patient had not been made…

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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 to carry the coils into the fallopian tubes. Multiple attempts were taken to place the…

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