Q: We recently had attending physicians send back queries with responses by the physician assistant (PA) or nurse practitioner (NP) who documented for them. Is it acceptable for a PA or NP to answer queries after the patient is discharged?Read More »
Q: In terms of coding blood transfusions, does the documentation of which intravenous (IV) site used has to come from the physician in the progress note, or can this particular information be extrapolated from nursing notes, orders, etc.? Read More »
Q: Is there guidance on reviewing a record, such as an operative (OP) note, that has not been signed by a physician? I am at a facility that allows coding from unsigned transcriptions. I was always told that the information needs to be confirmed by a signature as valid before including...Read More »
Q: CMS released guidance this summer about not auditing or counting errors for the specificity of an ICD-10-CM code. CMS is not going to count the code as an error as long as the first three digits are correct. Does this apply to medical necessity diagnoses and edits. Read More »