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Wiki Explain to Doctors

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coder21

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How can I explain to my doctor's how to give points in the number of diagnoses and management options?

Thank you in advance.
 
Do you have a copy of the audit tool?

Do you have a copy of the audit tool? It's laid out pretty clearly, I think (but then I think E/M is pretty easy).

You might want to consider having your doc check out www.emuniversity.com for additional help. Signing on is free and there is a wealth of information there.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Yes, I do have a audit sheet. So can I ask you a question. If a patient comes in with a new problem and no additional work up. Would you give 3 points? For example sore throat or eye pain?
 
Depends

Depends on whether the "new" problem is "Self-limited or minor" ... A cold will go away by itself without any effort. Even if it's a "new" problem, I would only give 1 point for that.

A sore throat with no fever, runny nose, chest congestion, etc may be a self-limited problem. Or it may be the first sign of strep throat (especially if there has been exposure - say a sibling had strep in the last couple of weeks).

So much depends on how the physician documents his/her thought process.

Sorry I can't be more definitive than that.

F Tessa Bartels, CPC, CEMC
 
Ok one more question. Thank you for all your help. We are a urgent care office. Say a patient came in in 2008 for a back injury which is a new problem. Then they came back in 2010 for a back injury again. They haven't been seen since the 08 visit. Would this be a new problem or and established problem?

Thank you again for all your help.
 
Urgent care and injuries

Unless you are consistently following the patient for the same injury, it's a new injury, so it's a new problem.

Same thing happens in a family practice or pediatrician's office. Patient presents with a URI in Feb 2008. When the same patient comes in with a URI in Nov 2009 it's a new problem again (even though it's an established patient).

F Tessa Bartels, CPC, CEMC
 
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