Wiki 1997 e/m guidelines

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veloso

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Hello to all!
I have four questions using the 1997 E/M Guidelines:
1. Neck;supple,lymhphadenopathy (HOW MANY BULLETS?)

2.Neuro;gait normal,tone and reflexes, alert-oriented x3 (HOW MANY BULLETS?)


2.If the final DX. is Bronchitis but the Exam is normal but in the Ros is positive, to I have to query the physician?

3.For Est.Visits the HPI is EPF and sometimes PF because there's always no ROS but the exam is always DETAILED and the MDM is always moderate (especially that our establishment is treating mostly HIV patients) can I consider always the EXAM AND MDM if the elements in the HPI is insufficient for a LEVEL 4.(2 OUT OF 3 COMPONENTS)

THANKS
 
1. Neck;supple,lymhphadenopathy (HOW MANY BULLETS?)
1 under MS for neck supple. With the lymph piece you have to check at least 2 areas to get any credit at all so they need to be more specific. Like neck and axilla.

2.Neuro;gait normal,tone and reflexes, alert-oriented x3 (HOW MANY BULLETS?) 2, gait is 1 under MS and A&Ox3 is 1 under psych. tone and reflexes is not specific enough for me to give credit.


2.If the final DX. is Bronchitis but the Exam is normal but in the Ros is positive, to I have to query the physician? Are your providers using EMR that is automatically throwing the exam in and they have to manually change it?

3.For Est.Visits the HPI is EPF and sometimes PF because there's always no ROS but the exam is always DETAILED and the MDM is always moderate (especially that our establishment is treating mostly HIV patients) can I consider always the EXAM AND MDM if the elements in the HPI is insufficient for a LEVEL 4.(2 OUT OF 3 COMPONENTS)
Again, I would like to know about the EMR possibility for this question as well. Usually the exam is the part we drop for leveling on established patients. There is nothing wrong with using exam and MDM but I just wonder if it is actually being done and not just copying over. Also with your MDM, I am going to assume you have more than just one issue going on because HIV alone is not going to get you moderate everytime. Once it is established/stable it is only 1 point.

Laura, CPC, CPMA, CEMC
 
Thanks a lot ,Laura yes,you're right we're using the EMR and the providers exam most of the time the same elements of systems (repeated for every encounter)like what I described above BUT it differs only to one particular system to which the CC is about,it is okey?
 
Thanks a lot Laura.Yes,we're using EMR,so the providers they use same notation for same encounter repeatedly in the exam as described above BUT they will put different notes to the specific system for which the CC related to,it is okey?
And to the HIV patients most of the time they have co-morbidities DX,like
Pneumonia,Asthma,etc.so in this case it is still moderate MDM?
 
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