Take the challenge. CPT: 99213-25, 77085 ICD-10: Diagnosis M81.0, Z79.52 The encounter is coded as 9913 as follows: History—The history of the present illness was extended. The review of systems was complete, and the past medical history was documented. This makes the history detailed. Examination—The examination was expanded problem focused. Medical decision making—The diagnosis was…
Avoid the Trap of Balance Billing
It is no secret that payers and providers have conflict as it relates to reimbursement rates for medical services, and there is another stakeholder, the patient, that plays an important role in the financial impact of healthcare reimbursement. Usually, patients are faced with unforeseen bills from their providers due to an unpaid portion of a…
Rheumatology Coding Corner Question: Office Visit with DEXA Scan
A 67-year-old female patient with Medicare returns to the office for a follow-up of her age-related osteoporosis. She states she has an achy pain in her left hip that lasts for 30–40 minutes in the morning. Currently, she has taken ibandronate sodium and alendronate sodium for the past year, and her pain level is a…
Patient Can’t Always Access Complete Medical Records, Doctors Say
(Reuters Health)—Technology makes it possible for patients to access medical records online, but a thicket of legal issues may still keep people from always seeing everything in their chart, some doctors say. The Health Insurance Portability and Accountability Act (HIPAA) gives U.S. patients the right to access their medical records and control who else has…
Rheumatology Coding Corner Question: Documentation Improvement
A 55-year-old female patient returns for her second infliximab infusion. Her temperature is 98°F, her height is 5’6″ and her weight is 151 lbs. She received 210 mg infliximab via infusion. The patient arrived at the clinic at 8:15 a.m. and left at 10:55 a.m. Can this encounter be coded correctly? Yes No A 38-year-old…
Rheumatology Coding Corner Answer: Documentation Improvement
Take the challenge. B—No. Although the documentation states the patient arrived at the clinic at 8:15 a.m. and left the clinic at 10:55 a.m., it does not document the actual start and stop times of the infusion. According to CPT, when reporting codes for which infusion time is a factor, use the actual time over…
Preparing for Increased HIPAA Audits Among Smaller Rheumatology Providers
Recent enforcement activities of the Department of Health and Human Services’ Office for Civil Rights (OCR) have shown an increase in fines and penalties assessed against smaller providers for failing to comply with the privacy, security and breach notification requirements of the Health Insurance Portability and Accountability Act (HIPAA). Historically, OCR has focused on larger…
Role of Dietitians in Rheumatology
What do dietitians do to help manage patients with rheumatic disease? Dietitians are well integrated, for example, in the practice of nephrology and diabetes, but few are active in the specialty of rheumatology. However, dietitians are recognized as part of the team of providers designated to care for patients with rheumatic disease by the ACR….
Implementing Successful Care Management Programs for High-Cost Patients
As healthcare delivery increasingly moves from volume-based care to value-based care, providers are needing to adopt new practices to meet what is now commonly referred to as the triple aim of healthcare delivery—improving the patient experience of care (which includes satisfaction and quality), improving the health of populations and reducing cost.1 Among the most difficult…
Addressing the Rheumatology Workforce Shortage
In 2008, the American College of Rheumatology Workforce Study Advisory Group published a comprehensive rheumatology workforce analysis.1 It concluded: Based on assessment of supply and demand under current scenarios, the demand for rheumatologists is expected to exceed supply in the coming decades. Strategies for the profession to adapt to this changing health care landscape include…
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