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Give Credit or Not?

  1. #1
    Arrow Give Credit or Not?
    Medical Coding Books
    Good Morning ALL -

    I am auditing 10 records from a physician who repeatedly puts "as outlined above" for his Review of Systems. Now in the HPI some of the records don't have enough elements to constitute a comprehensive. There were only 2 charts that he did list all the pertinent ROS and exam elements.

    Any comments?

  2. #2
    Indianapolis, IN
    If it's there, I give them credit (as long as it's not being used somewhere else - no double dipping of course).
    If it says "as outlined above" and there's nothing there, tell them you can't count what's not documented. (can't count as negative just becuase it's not documented as a positive).
    We can tell by your question that you already know the answer and just wanted confirmation - you are correct :^)

  3. #3
    North Carolina
    I would allow credit for something similar to this......(if no double dipping took place)

    CC: Fever, SOB
    HPI: The patient is a 72 yr old female who presented to the ED complaining of almost a week of mild, increased SOB, increased fatigue, non-productive cough, and fever of up to 101. Tylenol taken for fever w/o relief. Patient has chills, headache with cough. Chest pain with coughing only. Denies hearing problems and dizziness.

    ROS: as outlined above....

    I agree with Smathis1 that "If it says "as outlined above" and there's nothing there, tell them you can't count what's not documented. (can't count as negative just becuase it's not documented as a positive)." *Nicely said*

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