Part B Insider (Multispecialty) Coding Alert
Go Beyond The SOAP Note
Published on Wed Dec 17, 2003 
PDF
PDF
When taking a history, many doctors are used to obtaining a simple Subjective Objective Assessment and Plan (SOAP) note, which provides all the information they need for the review of systems, but not enough information for the history of present illness or past family and social history, consultant Barbara Cobuzzi says.
"A SOAP note just reviews what's going on with the systems," she says. So you should encourage your physicians to think in terms of HPI and PFSH as well as ROS.
Other Articles in this issue of
Part B Insider (Multispecialty) Coding Alert
- Evaluation:
Resolution to Stop E/M Code Revisions Goes to Trustees
AMA reconsiders 'clinical examples'
Evaluation and management codes may not move from [...] - History:
Those Who Take a Lousy History Are Condemned to Repent It
4 tips on obtaining a great patient history
It only takes a few minutes for your [...] - Go Beyond The SOAP Note
When taking a history, many doctors are used to obtaining a simple Subjective Objective Assessment [...] - History:
Make Sense of a Single Paragraph
Learn to dissect jumbled history into three categories
Many coders expect the physician to separate notes [...] - History:
Don't Use HPI Info to Satisfy ROS
In a recent set of "frequently asked questions," Part B carrier National Heritage Insurance Co. [...] - Legislation:
Providers Win Regulatory Relief in Medicare Bill
You can correct minor errors without pulling your own teeth
If you're drowning in Medicare paperwork, [...] - ALJs Move Out of Social Security Administration
Not all of the items passed in the "Regulatory Reform" section of the newly enacted [...] - Modifiers:
Bill Separately for Decision to Operate
Understand the difference between modifiers -57 and -25
Before she picks up a scalpel, the surgeon [...] - Physician Notes:
Reform Bill Calls for Twice-Yearly ICD-9 Updates
A provision that nobody noticed beforehand sneaked into the Medicare reform bill signed by President [...]
View All