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PLAIDMAN

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Hope someone can shed light for me

I was trained to code from "notes" tab in chart review. In the note the Dr is stating "no past surgical hx on file" (they still dictate)

but , If I look in the "encounters" tab I can see the link to history, and I can see a history entered WITH a surgical hx.

Can I count this for E/M? even though doc is stating no hx on file in his note?

would an auditor even look for the link if doc is stating no hx?

any thoughts would be helpful
thx
 
In EPIC you can see when the history was updated last even when it's carried it's carrier over from another encounter. That will show that the Dr. Reviewed and updated it. You should not use it if the Dr. is stating no history because it probably wasn't reviwed, he can't get credit for it, and that would be a cloning no no. You should check and see when the history was lastly updated, what date stamp it has on it in epic, and double check with the doctor if he did review or not, it could be a missed element.
 
Well, I was planning on sending it back to doc, because it is a NEW patient.... "no hx on file" ?.... new pt=collect hx

I can see where the hx was reviewed on this new pt, but it was reviewed,signed by the MA



thx for the help, it appears this is a bigger can of worms than I thought.
 
I agree with roxbejinariu, you should double check with the doc. It could have been overlooked or missed.
 
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