AmandaW
Guru
I understand each note has to be able to stand alone, but say for instance all details are given in the H&P by the physician. All those details have to be carried over to each visit to be coded that way?
Example...patients with Medicaid OB only.
Patient has a post-epidural spinal headache from anesthesia for delivery. So, patient is pregnant, and according to this documentation I can submit a pregnancy related code which Medicaid OB is looking for. 668.8x.
But on the subsequent visits the Dr will just say something like "her headache is better" and not go into all the pregnancy info and how it's from the epidural, etc. But of course he already stated all those details from the jump in the H&P.
We're taught that the patient's stay is a "story" but can we code it as such or have to code only page by page by page by page...leaving those subsequent visits to be coded only simply as a headache 784.0 ?
Example...patients with Medicaid OB only.
Patient has a post-epidural spinal headache from anesthesia for delivery. So, patient is pregnant, and according to this documentation I can submit a pregnancy related code which Medicaid OB is looking for. 668.8x.
But on the subsequent visits the Dr will just say something like "her headache is better" and not go into all the pregnancy info and how it's from the epidural, etc. But of course he already stated all those details from the jump in the H&P.
We're taught that the patient's stay is a "story" but can we code it as such or have to code only page by page by page by page...leaving those subsequent visits to be coded only simply as a headache 784.0 ?
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