Tips Tricks and Potent Quotables for Higher Coding

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So now that we have a few months under our belts, let's contribute some stuff to help enable higher levels of coding. No need for disclaimer about doing dumb unethical stuff.

Let's start - stress/demand that referring docs ALWAYS send recent labs along with their own note for patients regardless of referring pathology. Obviously diabetics is the easy one. Referral note + Hba1c + another lab relevant like BUN/creatinine is the 3 data points to support level 4 billing. Something as simple as them not sending labs can make higher billing harder. And more importantly it's good medicine.

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So now that we have a few months under our belts, let's contribute some stuff to help enable higher levels of coding. No need for disclaimer about doing dumb unethical stuff.

Let's start - stress/demand that referring docs ALWAYS send recent labs along with their own note for patients regardless of referring pathology. Obviously diabetics is the easy one. Referral note + Hba1c + another lab relevant like BUN/creatinine is the 3 data points to support level 4 billing. Something as simple as them not sending labs can make higher billing harder. And more importantly it's good medicine.

Good luck demanding a PCP to send their patients labs/documents. You will spend more time calling their office repeatedly requesting these things
 
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make sure always to describe sneakers as "shoe gear" to add complexity
 
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Use the high relevance Z codes that demonstrate your patients health issues to support your medical/surgical decision making.

ie.
inpatient hospitalization within 30 days
dependence on renal dialysis
chronic anticoagulation
history of foot/leg amputation
Personal history of diabetic foot ulceration
Insulin dependent

The other day I booked a bunion surgery and the patient's mom said she had a PE when she was 25. There's a Z code for family history of other circulatory problem - not very specific but creates a record of the decision making we explored.

As I write this post I just realized - there's a Z code for prior PVD treatment - Peripheral vascular angioplasty status with implants and grafts

Make sure that high risk problems are saved into their problem list to be included with whatever visit diagnosis they have if relevant. I was recently referred a patient for plantar fascial surgery with no documentation in their chart that they were diabetic, more specifically an uncontrolled diabetic. The person treating them likely undercoded at least some of the visits since they weren't just treating plantar fasciitis - they were treating DM2 Uncontrolled and plantar fasciitis.
 
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This one is a joke: whenever someone presents for another problem - check to see if they have onychomycosis. Terbinafine. Boom. Level 4!

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Good luck demanding a PCP to send their patients labs/documents. You will spend more time calling their office repeatedly requesting these things

And this is why being part of a large medial group is crucial for billing.
 
And this is why being part of a large medial group is crucial for billing.
Yeah my first job was a one stop medical group. 100 docs. Loved being able to log in and see everything nwith a click of the button. Better medical care IMHO
 
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Good luck demanding a PCP to send their patients labs/documents. You will spend more time calling their office repeatedly requesting these things

I don’t think I’ve received a single referral that doesn’t have demographic info and the last chart note attached to the fax. And that’s as an independent doc on a different EMR from every other doc that refers to me.
 
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I don’t think I’ve received a single referral that doesn’t have demographic info and the last chart note attached to the fax. And that’s as an independent doc on a different EMR from every other doc that refers to me.
I'm seeing this as well with the referrals I'm getting. I'm also seeing the PCPs sending the last labs without me even asking. I'm guessing that other specialists have asked for labs as well and the PCPs are just making it standard with the referrals they send.
 
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