In Coding
Jun 7th, 2018
Each time you meet with a patient, you should document a 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.” Simply stated, the chief complaint is a description of why the ...
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 ...
By: Diana Williams BS CPC CCS-P CCS CPMA The primary purpose of health record documentation is for continuity of patient care, and as a means of communicating among all healthcare providers. This clinical documentation captures the patient’s medical condition(s); hence, attention to documentation should be a priority for clinical providers. According to the Centers for ...
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 Billing
Feb 23rd, 2015
Meeting documentation requirements for coding shouldn’t be a burden. Five pointers can go a long way to ensure that your documentation leads to accurate coding for the services you provide. 1. Document Your Decision Making In the eyes of a coder (or auditor), “Not documented = Not done.” But, the provider can’t document everything, and irrelevant details ...