Sep 4th, 2012
When reading a chart note, it can be difficult to distinguish between elements belonging to the review of systems (ROS), and those elements that are relevant to the exam. The ROS are written or verbal “questions and answers” relevant to signs or symptoms the patient is experiencing at the time of service. Often, the ROS ...
Sep 1st, 2012
By Thomas A. Maher, CPA, CPC Are you intrigued at the prospect of reducing your medical claims coding costs? Have you heard the promise of an electronic health record (EHR) that will eliminate your paper records and choose billable codes for you? My advice: If it sounds too good to be true, it probably is. ...
Aug 1st, 2012
By Erin Andersen, CPC, CHC The age of electronic health records (EHRs) has begun. The days of deciphering illegible chicken scratches, cajoling busy physicians to write more than 10 words, and extensive searches for missing charts will one day be extinct. The EHR allows coders to work from home, promises a more complete record, timesaving ...
Jul 1st, 2011
Replace bad coding habits with good ones to get the best possible reimbursement. By Jacqueline Nash-Bloink, MBA, CPC-I, CPC, CMRS Hierarchical Condition Category (HCC) coding is a method of determining reimbursement based on the patient’s diagnosis. Generally, the more severe the diagnosis, the higher the reimbursement. HCC coding differs from CPT®-based evaluation and management (E/M) ...
Jul 1st, 2009
Part 2 of this three-part series provides an in-depth look at the exam component. By G. John Verhovshek, MA, CPC In this three-part series on the driving components of level selection for the majority of evaluation and management (E/M) services, we discuss the history, examination, and medical decision-making components. In May’s issue of Coding Edge, ...