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documentation improvement

  1. L

    Wiki R39.14 vs R33.8

    Here is an example of documentation with some of our providers: They also sometimes say something like: PVR of 68 mL indicating incomplete bladder emptying. Here is the link that I am referring to...
  2. A

    Wiki Does anyone have good documentation formats for ophthalmologist outpatient procedure?

    Hi all, Could anyone help me with good documentation formats for ophthalmologist outpatient procedure such as blepharotomy, drainage of abscess, eyelid, retrobulbar injection etc. :)
  3. S

    Wiki Intermediate/complex Repair documentation

    Our complex or intermediate repair notes will say closed with buried #__ polysorb sutures and # ___nylon sutures. Does not directly state layered repair or what layer of tissue they are closing with those sutures. Is this not required information? Or is stating buried sutures enough...
    • SUN1633
    • Thread
    • complex repair documentation improvement intermediate
    • Replies: 1
    • Forum: Dermatology
  4. H

    Wiki Physical Exam Documentation help

    I'm an internal auditor and I have run into some exam documentation that I have not encountered before. The physician is using "denies" within the exam section which to me is more like ROS documentation, not physical exam. Musculoskeletal: Wrists Denies swelling, denies tenderness Ankles...
  5. J

    Wiki Documentation Improvement - CRC exam

    Good Afternoon, I have attempted my CRC exam twice and have come really, really close. I keep falling "short" in the area of "Documentation Improvement" I have the study guide (well, partially. Chapters 6-11) Is there any "hope for me"? I have read all the materials I have and all of my scores...
    • jrodriquez
    • Thread
    • crc exam crc-risk adjustment coder documentation improvement
    • Replies: 6
    • Forum: Risk Adjustment
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