Part B Insider (Multispecialty) Coding Alert

Published on Fri May 16, 2008 PDF

Would you be able to count E/M bullets properly if the physician wrote -WBC WNL-?

If you can't differentiate - such terms as PH and PI, your coding may suffer.

Here's why: When the physician documents a chart, he doesn't always have time to spell out phrases such as -past history- (PH) and -present illness- (PI), but knowing which is which can make a tremendous difference in the accuracy of your charts. If you code a chart assuming that the patient currently suffers from every condition listed as -PH,- you-ll be coding the wrong diagnoses for the current illness.

Because of the extended disease and procedure names in the healthcare world, physicians use a system of communication using acronyms and abbreviations to facilitate more efficient communication among other medical professionals.

What is it? An acronym is a word formed from the initial letter (or letters) of words in a phrase or multi-word description. 

Unfortunately, in addition to being more efficient, the onslaught of acronyms has increased the possibility of error because of misunderstandings of the acronym or abbreviation. For instance, you may see a radiology report that refers to -FS,- which could indicate a -fracture, simple- or may just mean that the film was shot while the patient's forearm was supinated. 

Best bet: Get to know the most frequent acronyms for your practice.

-I memorize them,- says Kay Brown, CPC, of Bayou Anesthesia and Pain in Spring, Texas. -When I come across one I have not seen before, I have a coders- dictionary that I use, and I also look on Web MD.-

And when all else fails, you can ask the physician who documented the acronym for a definition.

Example 1: The physician documents the following note: -35 y.o. new pt. requires treatment for UTI determined by abn. C&S.-

In this case, a 35-year-old new patient required treatment for a urinary tract infection (UTI) that the urologist diagnosed via an abnormal (abn.) culture and sensitivity test (C&S).

Example 2: Suppose the doctor documents that the WBC is WNL.

In this example, the patient's white blood count is within normal limits, says Randall Karpf of East Billing in East Hartford, Conn.