Hospital visits

im051402

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Hello: I am a physician working as a Hospitalist. I also have an interest in coding and studying for the CEMC exam.

My questions to the experts here are:

1. For CC is it okay if I state "f/u HTN" or "F/u anemia" ? Since I see only inpatients I am always the one initiating the visit and not the other way around.

2. I am having difficulty with the 1995 GL regarding the physical exam. They seem too vague. Here is one of my standard f/u visit exams:

vs: 99 f 80 135/70 100% RA
NAD, CTA Bilateral, no increase WOB, RRR, abd: soft NT bs+, no c/c (clubbing or cyanosis) and no LE edema.

of course, this is just an example. Sometimes I add more if there is important findings. So would you say this is an expanded problem focus or detailed exam if you were reviewing it. To me it would be a detailed based on 1995 but an EPF with the 1997. Any help is always appreciated.

Mark
 

LLovett

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Your chief complaint is fine, just make sure you put one on every day you see the patient.

I agree on your exam, detailed based on 95 and expanded problem focused based on 97.

Laura, CPC, CPMA, CEMC
 

im051402

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Thank you, Laura. It's good to know. I try to stay as compliant as I can and review most if not all of my notes in real time to determine my own level of service.
 
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