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Exam and HPI

  1. Default Exam and HPI
    Medical Coding Books
    What is the rule of thumb for this, any help would be appreciated...

    In the HPI, pt CC is rash on the abdomen and arms, and only has been discussed in these two areas for the HPI.

    In the exam, the rash is discussed on the abdomen and arms. The head, neck, chest, back and legs were also examined negative of the rash. When determining the level of service would you count the exam as "3" (based on 95 guidelines) or would you count this as "8" because these areas were also examined?

    Thanks!

    Denise :0)

  2. Default
    My opinion is from what I'm reading from your excerpt is that the provider if the provider documents "no rash" or gives a description of a rash to certain area(s) of the body then the credit just should be given for skin.

  3. Default
    I would think only '1' for the skin. I'm sorry but from the information provided, I do not see 3 or 8. Hope this helps.

  4. Talking
    Quote Originally Posted by codegirl0422 View Post
    I would think only '1' for the skin. I'm sorry but from the information provided, I do not see 3 or 8. Hope this helps.
    We use the 95 guidelines, so what is used are the body areas (head, neck, back, abdomen, extremities, buttocks, and chest.

    Thank you both for your insight!

    Denise

  5. Default
    I would use the 97 guidelines for this case.

  6. #6
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    Default
    You are really dealing with an organ system... even if you are looking at each body area, it's still one organ system. I think you have an expanded problem focused exam. Just one coders opinion...

  7. Default
    I usually use 95 guidelines also. This is my understanding, if there is a rash, the rash is on the skin, the skin is the only organ system that would be selected. Again my understanding is you would not select each body area the rash is on. I asked a local auditor here, and that is what she said also. This is way I interrupt the guidelines. Are there any other opinions?

    Quote Originally Posted by dscoder74 View Post
    We use the 95 guidelines, so what is used are the body areas (head, neck, back, abdomen, extremities, buttocks, and chest.

    Thank you both for your insight!

    Denise

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