Q: A physician performed a pleural catheter flush using saline with manual clearance of clots under ultrasound guidance. Should we bill an E/M code for an outpatient office visit or report this using other CPT codes?
Q: The Office for Civil Righs (OCR) has settled its first case related to its Right of Access initiative. What is important to know about this from a security standpoint? Where are common security missteps with releasing information to patients upon request?
Q: What is the process for submitting a claim for an inpatient hospitalization when our utilization review committee determined after discharge that the inpatient admission was not medically necessary?
Q: Our coding department was told there were changes made for fiscal year (FY) 2020 when it comes to reporting healed/healing pressure ulcers and pressure-induced deep tissue damage. Can you explain any recent updates?
Q: Our facility sees a lot of patients dealing with diabetes and diabetic complications. Do you have any advice for helping these patients during their stay or after discharge?
Q: I’ve heard conflicting information about reporting uncertain diagnoses. Do the ICD-10-CM diagnoses need to be documented in the discharge summary/final progress note or can they be coded from an earlier progress note?
Q: If a patient is requesting his medical records via email, so long as our email is encrypted and secure, can we send it? We only have his email on his admission papers, which matches the email address he sent to us.