veloso
Expert
I'm new to this clinic in fact their very first hired coder but, i have been a surgical coder only for 5 years.Now I'm assigned to audit each encounter through EMR and most of the physician doesn't know how to document and code for a split visit.They always put in their assessment V70.0 plus additional sick diagnosis code with preventive visit only.So,my dilemma is how it is documented in the progress notes which goes like this example:
HPI: First visit w/ the PCP needs PE.
GEN.ROS:Gen.appearance,etc,positive for chest pain intermittently for 3 mos.
and neg with the other ROS.
PSFH;Complete
EXAM;2-9 Elements
ASSESSMENT:V70.0;042;401.9 ;786.50
TREATMENT;LAB;VENIPUNCTURE;EKG
Pls.I really need your help on how to code for this encounter?
HPI: First visit w/ the PCP needs PE.
GEN.ROS:Gen.appearance,etc,positive for chest pain intermittently for 3 mos.
and neg with the other ROS.
PSFH;Complete
EXAM;2-9 Elements
ASSESSMENT:V70.0;042;401.9 ;786.50
TREATMENT;LAB;VENIPUNCTURE;EKG
Pls.I really need your help on how to code for this encounter?