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  1. #11
    Medical Coding Books
    AF = Afib, and VSS = vital signs stable. 1 for cardiovascular and 1 for constitutional.

    I utilize the 1997 guidelines which states, should include at least six elements of the Exam for EPF. ??? I'm not counting that. Am I missing something?/?
    Last edited by krssy70; 03-05-2010 at 01:49 PM.
    Kristen Richard, CPC

  2. #12
    Milwaukee WI
    Default Interval history or exam
    I took AF and VSS to be part of the interval history - does not read like exam to me.

    If you are using 1997 guidelines you would have to specify the values of three vital signs to get one point for constitutional, so you STILL do not get constitutional exam points for VSS.

    Here's what I see as your only exam:
    abd: soft, obese, nt, incision c/d/i, some fullness in the incision area c/w a post-op seroma

    If you are using 1997 guidelines - here are the bullet points you can count:
    * Examination of abdomen with notation of presence of masses or tenderness
    * Examination of liver and spleen
    * Examination for presence or absence of hernia
    * Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses
    * Obtain stool sample for occult blood test when indicated

    * Inspection of skin and subcutatneous tissue (e.g. rashes, lesions, ulcers)
    * Palpation of skin and subcutaneous tissue (e.g. induration, subcutaneous nodules, tightening)

    I do not see that you get ANY points for abdominal/GI exam if you are using 1997 guidelines. The only bullet point you would get with this documentation would be for skin (because of the incision being C/D/I and the possible seroma) - and I'm being generous there.

    F Tessa Bartels, CPC, CEMC
    Last edited by FTessaBartels; 03-05-2010 at 04:33 PM.

  3. #13
    Thank you for all of that info. I really appreciate it. It helps alot. My only question is for VSS. Would the physician have to state each vital separately in order to get 1 credit for constitutional? Because the vital signs are documented in the patients inpatient chart, (EMR). This can be something I can educate the physicians on. Again, thank you for your help.
    Kristen Richard, CPC

  4. #14
    Milwaukee WI
    Default PHysician must document exam
    The physician must document the exam. This portion of the documentation is a record of the physician's own personal examination of the patient and his/her findings on that exam.

    I really think the notation "VSS" is part of the interval history in this case. The physician is noting what hospital staff has recorded in the chart since the last visit - i.e. the interval history.

    F Tessa Bartels, CPC, CEMC

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