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Performance Status

  1. #1
    Default Performance Status
    Medical Coding Books
    Hello:

    I would like to know where in the E/M you would count the "performance status". It is a common part in the history section of an oncology note. A provider may state "performance status 1". (It is usually a number or %age depending on which scale of measure is used.)
    I am interested to learn how different coders give credit for this statement when utilizing the audit tool.
    Thanks a bunch for everyone's insight.
    Karolina, CPC, CPMA, CEMC

  2. Default
    I usually see oncologists write this in the exam section, however, I do not know of any exam elements this would count towards. When coding, I typically do not count Performance Status for anything when in the exam. This is because I can usually get a comprehensive exam. If it is mentioned in the HPI, which I almost never see, I would consider crediting severity.

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