Sarah Ann
Networker
Urgent care coding-usually people are presenting with a simple problem- sore throat, rash, laceration etc. The EHR- most of the medications and conditions have been addressed by their primary, but because we use the same EHR the info. surrounding the "note" follows the patient from visit to visit.
Here's what I think and have always considered the "note" CC- ROS- Exam- MDM Assessment/plan.
In addition to that I am being told that because the physician signs the "note" which includes-- surrounding the actual note- the problem list the medication list(checked and collected by a nurse ,and the past, family, social history(collected by a nurse)-
Unless there's indication within the note itself I don't feel comfortable adding for instance any of the histories. I was told the other day that because the provider signs off on the note (and the other stuff is in the periphery) it's ok to use it because that means they reviewed everything- use what you need!??!!!!?
"we have to paint a picture of how sick this patient is" What?
"add all conditions that coexist-" Yes, if they address it-- has A- fib is on coumadin- I can see coding it. They are saying that evidence of the disease and treatment should be taken from the list of diseases- if there's a medication on the list that is usually used for one of the diseases on the list, then we can call that "treated", because they review the medications before signing- they're approving everything.
Just trying to get an idea of what others think- I could be going crazy!
Here's what I think and have always considered the "note" CC- ROS- Exam- MDM Assessment/plan.
In addition to that I am being told that because the physician signs the "note" which includes-- surrounding the actual note- the problem list the medication list(checked and collected by a nurse ,and the past, family, social history(collected by a nurse)-
Unless there's indication within the note itself I don't feel comfortable adding for instance any of the histories. I was told the other day that because the provider signs off on the note (and the other stuff is in the periphery) it's ok to use it because that means they reviewed everything- use what you need!??!!!!?
"we have to paint a picture of how sick this patient is" What?
"add all conditions that coexist-" Yes, if they address it-- has A- fib is on coumadin- I can see coding it. They are saying that evidence of the disease and treatment should be taken from the list of diseases- if there's a medication on the list that is usually used for one of the diseases on the list, then we can call that "treated", because they review the medications before signing- they're approving everything.
Just trying to get an idea of what others think- I could be going crazy!