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Wiki Another puzzle...

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btadlock1

btadlock1

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I'm checking a note and the CC is: "pt was ABT now has yeast infection"
"General health status fair. Whitish vaginal discharge with itching and redness since last week. Pt. recently completed a course of Augmentin x 10 days. Also concerned with irregular periods. LMP 12.10.10."

But then, under exam, it gets to GU, and he notes "exam deferred". What the hell?

Does he actually have to have examined something from the problematic organ system to receive credit for the E/M? Or are his medical decisions based on the patient's stated symptoms, and the other systems he examined, good enough on their own?

(Kind of seems like going to the doctor was pointless...)

Any thoughts are appreciated!!! :confused:
 
Didn't examine the problem

Well ... you could code it based on what WAS documented as examined, but it sure seems odd to completely ignore the presenting problem. Maybe the physician made a mistake in documenting?

(Scratching my head over this one ...)

F Tessa Bartels, CPC, CEMC
 
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