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Thread: E/M experts..

  1. #1

    Default E/M experts..

    Promo: Code Books
    My fellow coders:

    I'm trying to create a binder for evaluation and management to use as a reference for other employees/auditors.

    Instead of me trying to beat my head against the wall, I thought maybe you guys could help, that way I can compile the information much faster!

    Right now I'm trying to create a tool that will help easily identify what organ system/body area each documented item/problem/condition/symptom/illness belongs to for the review of systems and exam.

    Example(s):
    General/Constitutional
    Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct usual activities, exercise tolerance
    Skin/Breast
    Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes
    Breast lumps, tenderness, swelling, nipple discharge

    I'm basically trying to categorize the symptom/illnesses to the appropriate organ systems. Feel free to add your thoughts. Thanks!!

  2. #2
    Join Date
    Apr 2007
    Location
    Milwaukee WI
    Posts
    4,451

    Default My favorite reference

    I use the 1995 or 1997 exam guidelines / audit tools as my reference point.
    We're in pediatrics so many of the bullet points aren't applicable (especially male/female GU exams), but it still helps to categorize what system or body area we're talking about.

    No need to reinvent the wheel ... LOL

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Join Date
    Apr 2007
    Location
    Seacoast- Dover New Hampshire
    Posts
    605

    Default

    I am right in the middle of a similar situation. We have a new MD who wants some pointers as she believes she may be under coding. I have spent the afternoon searching for information to give her. She is Internal Medicine. Some of the things I have found are:
    Provider education Medicare Part B;
    Services Not Reasonable and Necessary
    E and M coding requirements
    IPPE 2009
    1995 and 1997 documentation Guidelines.
    Now, to put that into a quick snapshot.
    I have printed out the publications and will put them in a folder for the future, or until something changes.
    Karen Barron, CPC
    Hampton New Hampshire Chapter

  4. #4
    Join Date
    Apr 2007
    Location
    Watertown, NY
    Posts
    108

    Default

    KBarron,
    you can create a refernce sheet/cheat sheet for the doctor to refer to. the one i have has new, est & consults on it. if you need a copy send me an email at bigredcag@hotmail.com and state what specialty and if you want 95 or 97 or both.

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