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Wiki CC and A&P

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nikita0872

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We have this scenerio all the time: Patient comes in complains of runny nose and backache. He also has HTN, DM, Gout. etc.

A&P:
DM- stable. no change in meds.
HTN- stable. no change in meds.
Gout- order labs.

f/u 3 months or sooner.

So my question is since the provider never addressed the runny nose or backache do you still code them?

Any help is appreciated!!!
 
Hello there,

I would not code for the runny nose or backpain, because the provider did not address it in the documentation or the A/P.
I would, however, ask the provider if he did address the runny nose and backpain, assess and manage it with any type medication, or referred the patient possibly to a specialist for the backpain.
This could boost his E&M and reimbursement and cover him/her to address what the patient came in to see him/her for in the beginning.

Hope this helps,

Barbara
 
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