CHICAGO—In October of last year, a 52-year-old woman came to see Kevin Winthrop, MD, MPH, associate professor in infectious diseases, public health and preventive medicine at the Oregon Health & Sciences University. She had rheumatoid arthritis and was taking methotrexate and prednisone. She had had little change in her RA disease severity and was considering…
Forty-five years ago, a computer engineer in Boston sent an electronic message between two computers some 10 feet apart. It took another 10 years or so before the electronic mail message was dubbed email—a term now, perhaps, more ubiquitous than any other in the lexicon of modern communications. Despite the seemingly definitive place email communication…
Sometimes, life calls for you to be out of the office for a length of time. Whether the absence is planned or not, it’s important to consider the best actions to take given the circumstances to ensure patients are cared for during your absence. Alexa Meara, MD, clinical instructor and rheumatologist, The Ohio State University…
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…
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…
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…
(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…
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…
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…
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…