Kevinph84
Guest
I have confusion regarding the review of systems. I am a new coder, having almost a year of actual coding experience. Let me say the real world is nothing what school had pictured! My manager had saw my proficiency with E&M coding, and has been grooming me for our current system wide audit.
I was originally taught that a symptom being used in the HPI, can not be used in review of systems. This example is from an actual case.
"Patient is here with a skin infection." Then in the ROS, the physician only states "Generally feeling well, no other skin complaints." That statement only has me giving credit for for constitutional.
We currently have a consultant come on board to help provide physician education. The consultant has cited me for not selecting the "No other skin complaints." I told him my reasoning was that I was instructed it was double dipping. I understand his side, that the skin is our largest organ, and multiple concerns can errupt.
Another incident, the physician stated "No drug allergies". The consultant said I should use that for ROS, if there aren't any ROS available. I consider that a part PFS history, and another EM coder has agreed.
Can anyone give me some insight on this situation? I am confused that I could be undercoding or potentially overcoding. Is the consultant's view double dipping, or should I get some more of that dip? Thank you all for your time!
Respectfully Yours,
Kevin P. Honig, CPC-A
I was originally taught that a symptom being used in the HPI, can not be used in review of systems. This example is from an actual case.
"Patient is here with a skin infection." Then in the ROS, the physician only states "Generally feeling well, no other skin complaints." That statement only has me giving credit for for constitutional.
We currently have a consultant come on board to help provide physician education. The consultant has cited me for not selecting the "No other skin complaints." I told him my reasoning was that I was instructed it was double dipping. I understand his side, that the skin is our largest organ, and multiple concerns can errupt.
Another incident, the physician stated "No drug allergies". The consultant said I should use that for ROS, if there aren't any ROS available. I consider that a part PFS history, and another EM coder has agreed.
Can anyone give me some insight on this situation? I am confused that I could be undercoding or potentially overcoding. Is the consultant's view double dipping, or should I get some more of that dip? Thank you all for your time!
Respectfully Yours,
Kevin P. Honig, CPC-A