Wiki E/M experts..

[ARCPC9491]

My fellow coders:

I'm trying to create a binder for evaluation and management to use as a reference for other employees/auditors.

Instead of me trying to beat my head against the wall, I thought maybe you guys could help, that way I can compile the information much faster!

Right now I'm trying to create a tool that will help easily identify what organ system/body area each documented item/problem/condition/symptom/illness belongs to for the review of systems and exam.

Example(s):
General/Constitutional
Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct usual activities, exercise tolerance
Skin/Breast
Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes
Breast lumps, tenderness, swelling, nipple discharge

I'm basically trying to categorize the symptom/illnesses to the appropriate organ systems. Feel free to add your thoughts. Thanks!!

 

[FTessaBartels]

My favorite reference

I use the 1995 or 1997 exam guidelines / audit tools as my reference point.
We're in pediatrics so many of the bullet points aren't applicable (especially male/female GU exams), but it still helps to categorize what system or body area we're talking about.

No need to reinvent the wheel ... LOL

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[kbarron]

I am right in the middle of a similar situation. We have a new MD who wants some pointers as she believes she may be under coding. I have spent the afternoon searching for information to give her. She is Internal Medicine. Some of the things I have found are:
Provider education Medicare Part B;
Services Not Reasonable and Necessary
E and M coding requirements
IPPE 2009
1995 and 1997 documentation Guidelines.
Now, to put that into a quick snapshot.
I have printed out the publications and will put them in a folder for the future, or until something changes.

 

[bigredcag]

KBarron,
you can create a refernce sheet/cheat sheet for the doctor to refer to. the one i have has new, est & consults on it. if you need a copy send me an email at bigredcag@hotmail.com and state what specialty and if you want 95 or 97 or both.