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Help on the Review of Systems & Social History

  1. #1
    Default Help on the Review of Systems & Social History
    Medical Coding Books
    1.) I have a physician that is documenting the Patient's recent travel history and the patient's exposure to pets. I did not include that as part of the review of systems, because I consider that more of a social history. What would others do, or how do you include that type of documentation in your auditing?

    2.) This is another question involving the same physician. This particular physicians specialty is Infectious disease. I tried to explain the high complexity part of the MDM to her,by saying the patient must have a severe, life-threatening illness, or an illness with a severe exacerbation, and so forth. She responded by saying, all of my patients have illness that may pose threat to his/her life, but it's not to say they are going to die of the illness this day or the next couple days, or maybe not at all. So by saying that, she thinks all of her consults should be a level 5. The Physician obviously can't be billing all level V's, because that will definately trigger an audit, so how can I better explain to the physician MDM or the complexity of the problem.

    I hope this all makes sense, but I am trying to get this through to the physician and I'm having a really difficult time. Thanks to all that help.
    Tiffany Fischer, CPC, CEMC

  2. Cool Ros mdm...
    Wow - you sure have a frustrating situation going on.

    I think the saving grace in this situation is the fact that although the medical decision making may be high complexity, the balance of the encounter will weigh in heavily. In order to get level V's all the time would mean that every area of the encounter would have to come in at a super high level as well.

    I once worked for a doc that wanted level V's on everything as well. I showed him day after day, week after week, month after month (need I say more?) that although the complexity was high, the history and examination did not match the criteria required.

    When you audit the entire picture, what level do you come up with? Perhaps placing an audit tool in front of your doc might make her see the light of day?

    Good luck to you - I once sailed in the same boat and it is just frustrating.


  3. Wink Oops...the first part of your query...
    I'm wondering if you have enough PFSH to formulate a level without even considering the travel and pet issues...if not, I agree with you that they fall more under the social history. However, if you stretch your imagination, I suppose that pets could factor in if the patient has a pet/dander allergy?

    Don't you sometimes feel like you are sailing on the Titanic?

    Have a great weekend!


  4. #4
    Rose City (Portland, Oregon)
    1) I would count this for social history, too. My reasoning against ROS is - what system is travel? NONE It's not reviewing a system it is a notation on the patient's social history.

    2) What is important to point out is that it is the status of the patient TODAY and not what COULD be at some future point. Coding works in definites, not maybes. If the patient deteriorates, that visit would be high MDM. If the patient is doing ok today, on rx, it might only be a moderate. I would ask her if the drugs she prescribes require drugs intensive monitoring. Is she reviewing records, speaking to other doctors that she doesn't describe in her note. All of these things could lead to high mdm if documented.


  5. #5
    Thank you both so much! This helps by great means, I just hope I can get this through!!
    Tiffany Fischer, CPC, CEMC

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