In the outpatient setting, the diagnosis, condition, problem, or other reason for encounter/visit that is documented in the patient record as being chiefly responsible for the services provided is called the __________ diagnosis.
Read DetailsA Medicare beneficiary has a procedure to promote nerve regeneration at a pain management center. The patient is placed in a prone position, and a midline incision overlying the affected vertebrae is made. The fascia is divided and the paravertebral muscles are retracted. The physician places the inductive electrode pads in the epidural space proximal to the damaged spinal segment. The pulse generator is sutured over the muscles, just below the skin, and closed with a layer closure. What CPT procedure code is reported by the physician?
Read DetailsAn established patient sees his physician in the office with complaints of chest pain. The physician admits the patient on December 1 under observation status at the local community hospital. The physician completes a comprehensive history that includes a complete review of all body systems and a complete past, family, and social history. The physician performs a comprehensive examination but finds no significant issues. The patient does admit to a great deal of stress at work. Medical decision making is of moderate complexity. On the second day of care, the physician continues to observe the patient when he conducts a detailed examination and medical decision making of moderate complexity. The patient is subsequently discharged home the next day with a diagnosis of mild depression. The patient was in observation status for three days. What E&M codes would the physician report for the second day of care? CPT Code(s): _____________________________________________________________________
Read Details