E & M Diagnosis Codes

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Greenville, SC
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When coding or auditing the E & M, can you get a diagnosis from the dictated History when the dicatation has the diagnosis listed under the Assessment?

For example, the router or encounter form has a diagnosis marked, but the dicatation does not have that diagnosis listed in the Assessment, but it is mentioned in the History. The diagnosis in the History may be needed to obtain the level of the E & M that was indicated on the router or encounter form.

Also, does anyone know of a good book for auditing and coding E & M that would answer a question like this one?

Thank you,

Candice Brazeale, CPC
 
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Dx In Progress Note

When coding or auditing the E & M, can you get a diagnosis from the dictated History when the dicatation has the diagnosis listed under the Assessment?

For example, the router or encounter form has a diagnosis marked, but the dicatation does not have that diagnosis listed in the Assessment, but it is mentioned in the History. The diagnosis in the History may be needed to obtain the level of the E & M that was indicated on the router or encounter form.

Also, does anyone know of a good book for auditing and coding E & M that would answer a question like this one?

Thank you,

Candice Brazeale, CPC

THE DX SHOULD BE IN THE PROGRESS NOTE. IF THE DOCTOR IS MARKING HIS/HER DX IN THE ENCOUNTER FORM THEN HE/SHE SHOULD DOCUMENT IT IN THE PROGRESS NOTE TO SUPPORT HIS CLAIM...THAT WOULD BE FRAUD!

IN E/M YOU COULD ONLY USE THOSE DX IN PAST,FAMILY AND SOCIAL HISTORY(PFSH) IF DOCUMENTED AS PAST MEDICAL HISTORY OF THE PT.

HOPE THIS HELP !!!:)
 
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Milwaukee WI
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Candace,
I'm not sure if you are worried about double-dipping ...

But, yes, you can pull a diagnosis from the history section, as well as from the assessment section. After all, if you had no definitie diagnosis (but a few "Rule out") you'd code the signs/symptoms from the history section.

F Tessa Bartels, CPC, CPC-E/M
 
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6
Location
Greenville, SC
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Thank you for your responses, they are very helpful. I do need to clarify the History part of my question, as I was referring to the History of the present illness, not the past History.

Thank you again for your assistance.

Candice Brazeale, CPC
 
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