Initial Discussion Question/Prompt Due Wednesday by 11:59 pm
Instructions:
Review the SOAP notes accessed through this link.
(Links to an external site.)Current Procedures SOAP Note download
Construct a discussion that includes the following:
Identification of the procedures performed in each patient encounter
Assignment of CPT code for each procedure identified
Resources utilized for locating assigned CPT codes; if an online resource include the link to the site or page.
Discussion Peer/Participation Prompt Due Sunday by 11:59 pm
Instructions:
Construct a response to at least 2 of your peers ideally one who located/utilized the same resource(s) for locating CPT codes for the identified procedures and one who did not.
Include in your response discussion your impression of the value of the resource(s) for your role as an NP.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with in-text citations and corresponding references in APA format.
Please review the rubric to ensure that your response meets the criteria.
JUST NEED PEER RESPONSE PLEASE USE UPDATED REFERNCES AND I WILL PROVIDE BOTH PEERS POST.
PEER#1Collapse SubdiscussionBarbie Johnston
Barbie Johnston
WednesdayAug 18 at 6:02pm
Clinical Decision Making Week 14, CPT Codes
SOAP Note #1:
A 23-year-old female is having a Nexplanon contraceptive implant removed from under the skin. The CPT code 11976 is for the removal of an implantable contraceptive capsule (AAPC, 2021). She also had a urine pregnancy test, CPT 81025, and a Hgb A1c, CPT 83036 (AAPC, 2021). The patient reports an adverse reaction to the implanted contraceptive, a recurrent complaint of candida, and a detailed history and examination, and the ordering and review of labs. According to the American Medical Association (AMA), this would categorize the complexity of medical decision making (MDM) as moderate with CPT 99214 (AMA, 2019). Or if this was a new patient, the CPT would be 99204 (AMA, 2019).
99214 Moderate complexity
81025 Urine pregnancy test
83036 Hgb AIC
11976 Removal of an implantable contraceptive capsule
SOAP Note #2:
A 65 year-old-male presents with dysuria, urine frequency, and abdominal and flank pain. A urine dip stick was performed, CPT 81003, and was sent for culture and sensitivity, CPT 87181 (AAPC, 2021). For the purpose of the MDM, one test was ordered for an acute, uncomplicated illness of UTI. His stable, chronic illness of colon cancer is thought to be responsible for his second diagnosis of abdominal and flank pain. This would categorize the patient’s MDM at a low complexity (AMA, 2019). As an episodic/returning visit the CPT would be 99213 or if a new patient, a CPT of 99203 (AMA, 2019).
99213 Low complexity
81003 Urinalysis
87181 Culture & Sensitivity
SOAP Note #3:
A 68-year-old male presents with black stool and feelings of fatigue. A fecal occult blood test was performed with a CPT code of 82272, a hemoglobin and hematocrit with CPT of 85027, a CBC with CPT of 85025 and a CMP with GFR with a CPT of 80053 (AAPC, 2021). The MDM would be based on an illness with possible systemic symptoms, labs ordered and reviewed, and a consult with GI for an EGD. This would be considered moderate complexity (AMA, 2019). The CPT code for an established patient would be 99214 and for a new patient, 99204 (AMA, 2019).
99214 Moderate complexity
82272 Fecal occult blood test
85027 Hemoglobin and Hematocrit
85025 CBC
80053 CMP with GFR
CPT code lookup, CPT® codes and search – Codify by AAPC. (2021). Medical Coding – Medical Billing – Medical Auditing – AAPC. https://www.aapc.com/codes/cpt-codes/ (Links to an external site.)
CPT E/M Office Revisions Level of Medical Decision Making. (2019). American Medical Association. https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf (Links to an external site.)
Reply(BARB USED THE SIMILAR CODES AS I DID)
PEEER#2
Collapse SubdiscussionShaina Reguste
Shaina Reguste
WednesdayAug 18 at 11:38pm
Unit 14 Discussion – Current Procedural Terminology
CPT modifiers indicate if providers performed multiple procedures, why a service was medically necessary, and where on the patient the procedure occurred. Using CPT modifiers ensures that providers are correctly reimbursed for all services provided.
“Coding is critical as it can indirectly affect medical care, particularly as it relates to insurance reimbursements. In today’s fee-for-service medical environment, physicians are increasingly required to list underlying conditions, untreated diagnoses, and preconditions. Having the proper medical coding ensures that insurers have all the diagnostic codes required for appropriate payment. Coding is also critical for demographic assessments and studies of disease prevalence, treatment outcomes and accountability-based reimbursement systems.” (Bitar, J. (2021).
In clinicals I have learned that there are many missing CPT codes to describe certain procedures such as if a patient has a breast exam without having the complete female wellness examination components or for patients who have had a pelvic exam without having a pap smear or cytology. CPT codes are important but they can be very difficult to use when defining certain procedures that we perform on our patients as they might not exactly fit completely and for reimbursement purposes that may be an issue that could result in non compensation for rendering of service.
SOAP Note #1:
A twenty three year old white female, G0, obese presenting for Nexplanon removal. This implant has been in place in her left arm since August of 2017, however, she desires its early removal due to unintended weight gain and increased appetite, as well as uncontrollable mood lability. She does complain of symptoms suggestive of yeast infection. She has had recurrent yeast infections to the vulva and vagina area, otherwise she is doing well.
99214 (established visit, moderate complexity)
or 99204 (New Patient, moderate complexity)
81025 Urine pregnancy test
83036 Hgb AIC
11976 Removal of an implantable contraceptive capsule (Nexplanon removal)
There is no specific code for a pelvic exam that excludes a pap or wellness exam of a female
SOAP Note #2:
A 65 year old male with hx of Colon Cancer stage 3 that metastasized to liver and peritoneal presents with complaints of having pain when he voids as well as lower abdominal and back pain for the last three to four days.
99213 Low complexity Established patient or 99203 Low complexity New patient
81003 Urinalysis
87181 Culture & Sensitivity
99000-Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory
SOAP Note #3:
A 68 year old white male presenting with complaints of black stool for the past two to three days whom brought a sample into clinic today. He isalso complaining of feeling “sluggish and fatigued”.
99124 (established visit, moderate complexity) or 99204 (New Patient, moderate complexity)
82272 Fecal occult blood test
85027- Hemoglobin and hematocrit with platelet count
85025- Complete blood count with auto differential
80053 Complete Metabolic Panel with GFR
Reference
AAPC. (2021). Search. In Codify. Retrieved from https://www.aapc.com/codes/ (Links to an external site.)
American Medical Association. (2019). CPT E/M office revisions level of medical decision making (MDM). In American Medical Association. Retrieved
from https://www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf (Links to an external site.)
Bitar, J. (2021). Importance of medical billing and coding: Sochi. Southern California Health Institute. https://www.sochi.edu/blog/why-medical-billing- (Links to an external site.)
coding-is-important.html (Links to an external site.).
RePLY
