Dec 13th, 2016
Account for DRG and comorbidity adjustments and ensure all active medical treatments and diagnoses are documented. Part of our responsibility as healthcare business professionals is to understand the financial realities of healthcare delivery and reimbursement. For those of us working in mental health, this means learning the “ins and outs” of the Inpatient Psychiatric Facility ...
In Billing
Aug 4th, 2015
by Kerin Draak, CPC, CPC-I, CEMC, COBGC The CPT® codebook defines the Chief Complaint (CC) as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” CPT® recognizes five levels of presenting problems: Minimal, Self-limited or minor, Low severity, Moderate severity ...
In Audit
Mar 16th, 2015
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA In February, we examined how “labels” might cause an incorrect count of organ systems examined if an auditor doesn’t take care to read the details beyond the labels. For purposes of this discussion we will assume that the examination and complexity of MDM meet the proposed ...
In Coding
Sep 19th, 2014
A common problem with provider documentation is the missing chief complaint (CC). CPT® defines the CC as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” The 1995 and 1997 Documentation Guidelines for Evaluation and Management (E/M) Services specifically require, ...
One common problem with provider documentation is a missing chief complaint (CC). Unless the visit is for a preventive medicine service, the lack of a CC means that the service will be deemed medically unnecessary (and unpayable) by any insurer. Often, providers begin their subsequent notes with symptoms the patient may not have, or a comment ...