Editor's note: Medical Records Briefing (MRB) catches up this month with Monica Pappas, RHIA, president of MPA Consulting in Long Beach, Calif., and an MRB advisory board member, to discuss physician queries.
At the Association of Clinical Documentation Improvement Specialists (ACDIS), questions on physician queries are never few and far between. Although AHIMA has published a couple briefs on the topic over the last decade, questions have still remained about how to implement a compliant and effective query process.
Q. A long-term care facility has deployed laptops that connect to a file server and are password protected. The laptops are not used to store PHI or other confidential data and are not removed from the facility. Do the laptop hard drives need to be encrypted?
A death row inmate develops a lump near his breast and is sent to a local hospital for an examination. The physician wants to perform medical imaging to diagnose the lump, but correctional staff won't remove his shackles. It's impossible to perform the test wearing restraints. He returns to the prison without a diagnosis.
Our experts answer questions about modifiers for diagnostic interventional procedures, Medicare recognition of CPT® code 9066, reporting add-on code for psychotherapy with interactive complexity, reporting G0378 for all payers, and wound care coding.
CMS corrected edit 84, added five APCs to the I/OCE, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. In addition, CMS deleted all of the genetic testing modifiers, retroactive to January 1.
