A progress note from our nurse practitioner (NP) indicated that she was called by nursing to see a patient due to “unequal pupils.” The NP ordered a CT/CTA to rule out associated dissection or blood clot post angiogram earlier today. Would it be correct to assign a diagnosis code for unequal pupils as primary?
What time can be used for an infusion stop if the patient is in the clinic and has a negative reaction requiring inpatient admission?
If an infusion is stopped because the patient is having an adverse reaction to a drug, can we still charge for the infusion?
Can a subcutaneous injection of insulin administered to a patient be billed?
If an IV antibiotic was administered but the MAR only contains the time the infusion started, can we charge for an IV push?
We are wondering if you would provide some guidance regarding the use of CPT code 77071 – ‘Manual application of stress performed by a physician or other qualified health care professional for joint radiography…’? When stress imaging of a joint is performed, in order to charge for 77071 (as well as the joint /anatomic site and # of views) is it necessary that the report specifically document who applied the stress, similar to the ultrasound of infant hips with manipulation (76885)?
If you are coding a computed tomography (CT) with contrast exam, and the contrast amount and type is given within the technique, but the words “with IV contrast” are not specifically used, does this suffice for the with contrast requirements?
We have a referring physician that insists on ordering a unilateral screening mammogram on the same script as a unilateral diagnostic mammogram. Can you please advise as to the correctness of this order?
If you are coding a computed tomography (CT) with contrast exam, and the contrast amount and type is given within the technique, but the words “with IV contrast” are not specifically used, does this suffice for the with contrast requirements?
Where can I find the July 2020 OPPS information released by CMS?
When the technique of a nuclear medicine exam states that a whole-body exam was performed, must the doctor document each area of the body, or may the doctor dictate any issues found and then state “remainder of whole-body scan was unremarkable”?
What documentation does my doctor need to dictate to allow code 49405–49407 as opposed to 10160?
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