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E/M guidelines

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Ongoing discussion with other coders/auditors here:

If you find items of history or exam or MDM in areas not specified as such do you count them? For example if you find elements of history in the Assessment/Plan, do you count them?
 

LindaEV

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Absolutely. I use everything I can regardless of what section it is or what "heading" it is under. I just make sure not to double dip.
 

dmaec

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yes, sure do! It doesn't matter "where" it's located, not all doc's even dictated in the same format... some just have one large paragraph, all in one!!

but as LindaEV stated -- NO DOUBLE DIPPING!! :)
 

NaliniAAPC

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Hi,

Yes i too agree.You can count anywhere from the document, but no double dipping..:)

Nalini CPC
 

MnTwins29

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Not always labeled as such

Keep in mind that not all physicians will have the history, exam and MDM labeled as such (especially history items) so only being allowed to use items that are labled would be too restrictive.
 

LLovett

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I have to disagree with pulling HPI elements from the A&P. I don't really care what headers are used so that doesn't matter, but once you start telling me your assessment you are done getting HPI as far as I'm concerned.

Laura, CPC, CPMA, CEMC
 
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I posted this same question on the EM University website, and this was the answer I received from Dr. Peter Jensen. Lots of different opinions.

Just an FYI....

Username: pjensen
Message:
I think you can take some elements of history, such as items in the HPI which can also be used in the ROS, but some carriers consider this double-dipping and do not allow it. Check with your own carrier. As far as elements of history from the MDM, I do not think you can do this. I think what youare saying is, if in the assessment and plan, the doc describes a problem as stable, can I use this statement to help complete the HPI based on the "status of chronic or inactive problems." I don't think you can do this. My advice is to have doctors "surrender" and structure the note so that there all three key components can stand alone. Any other approach is simply too risky.

PJ
 

rthames052006

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I posted this same question on the EM University website, and this was the answer I received from Dr. Peter Jensen. Lots of different opinions.

Just an FYI....

Username: pjensen
Message:
I think you can take some elements of history, such as items in the HPI which can also be used in the ROS, but some carriers consider this double-dipping and do not allow it. Check with your own carrier. As far as elements of history from the MDM, I do not think you can do this. I think what youare saying is, if in the assessment and plan, the doc describes a problem as stable, can I use this statement to help complete the HPI based on the "status of chronic or inactive problems." I don't think you can do this. My advice is to have doctors "surrender" and structure the note so that there all three key components can stand alone. Any other approach is simply too risky.

PJ
I like what Dr. Jensen has stated " check with your carrier" at times when I'm doing his "case of the week" I get a differant level than he because I am following my MAC guidelines. The best thing to do in these cases is to consult with your carrier, as only they can tell you what they accept and do not accept.

Best of luck!
 

Pam Brooks

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I agree with Dr. Jensen about not using the status of the assessment "stable, chronic, improved" as part of the HPI. So for example, if you see Type II Diabetes, Uncontrolled as your assessment, I wouldn't use "uncontrolled" as a history element.

But there are times you'll find history components in the assessment....

For example, I have a hosptialist whose notes often ramble on and on....and within his assessment, he's still documenting history elements. For example, he might say something like , "I am going to increase insulin again because the fasting BG levels have continuously increased since last month when he saw his primary care physician".


Additionally, I often see this in the MS exam: "Considerable pain with flexion, extension and rotation of hips. Patient describes pain as 8 out of 10." That comment is not objective...it's subjective and qualifies for a severity bullet.

If E&M coding was easy and convenient, all providers would list all history, review, exam and assessment verbiage under the proper headings. But not all providers were trained in the same way, others are more verbal and explanatory, so I always use the entire note to support the elements of the key components. As long as you don't use the same information twice, are reasonable in what you give credit for, and would feel comfortable defending yourself in an audit, then I would use the documentation where you find it. E&M Coding is not really an exact science, it's more of an art....

You'll find that an EHR is making this a lot easier for coders. The elements are right where they need to be. The problem now,is that the docs get click happy and over-document.
 
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In my 16 years of coding, I was always instructed that each of the key components must "stand alone", as Peter Jensen suggests. It depends on the employer guidelines, and their expectations, which can differ from one company to another. Of the hundreds of thousands of charts I have coded, most providers are very good at documentation, and if not, are usually easily trained.

Coding is a crazy world, and getting crazier by the minute...
 
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