new to e/m
I am just starting to figure out how to do audits on our e/m coding and i have a question. If a pt is coming in for follow up to a cardiac cath with stent and his having no problems and the dr. documents subjective findings and using those same findings in the ros how do i figure out the correct e/m code? He did not do any PFSH either. i really need help with this. When the patient's are coming in for routine follow with no c/o i get very confused. the other thing is if dr. says pt denies chest pain, shortness of breath, nausea, vomiting, orthopnes under subjective then says the same under ros what can i give credit for? I am a little lost. If someone could help me i would appreciate it. shelly
I am also new to the e&m, my thinking is that when the dr. says denys sob,nausea ect that they actually get credit for that. The reason i say that is cause my dr. usually says noncontributory so then that means no credit at all. When there are follow ups to... like a procedure i would think the it would be v codes noting that it is follow up care.
Best way for us to help you
The best way for us to help you is for you to post a scrubbed note and we can help you dissect it.
Also, you may want to go to www.emuniversity.com and sign up for the "case of the week." This is a free service and you will learn a lot about E/M from it.
Hope that helps.
F Tessa Bartels, CPC, CEMC