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Explain to Doctors

  1. Default Explain to Doctors
    Medical Coding Books
    How can I explain to my doctor's how to give points in the number of diagnoses and management options?

    Thank you in advance.

  2. #2
    Milwaukee WI
    Default Do you have a copy of the audit tool?
    Do you have a copy of the audit tool? It's laid out pretty clearly, I think (but then I think E/M is pretty easy).

    You might want to consider having your doc check out for additional help. Signing on is free and there is a wealth of information there.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default
    Yes, I do have a audit sheet. So can I ask you a question. If a patient comes in with a new problem and no additional work up. Would you give 3 points? For example sore throat or eye pain?

  4. #4
    Milwaukee WI
    Default Depends
    Depends on whether the "new" problem is "Self-limited or minor" ... A cold will go away by itself without any effort. Even if it's a "new" problem, I would only give 1 point for that.

    A sore throat with no fever, runny nose, chest congestion, etc may be a self-limited problem. Or it may be the first sign of strep throat (especially if there has been exposure - say a sibling had strep in the last couple of weeks).

    So much depends on how the physician documents his/her thought process.

    Sorry I can't be more definitive than that.

    F Tessa Bartels, CPC, CEMC

  5. Default
    Ok one more question. Thank you for all your help. We are a urgent care office. Say a patient came in in 2008 for a back injury which is a new problem. Then they came back in 2010 for a back injury again. They haven't been seen since the 08 visit. Would this be a new problem or and established problem?

    Thank you again for all your help.

  6. #6
    Milwaukee WI
    Default Urgent care and injuries
    Unless you are consistently following the patient for the same injury, it's a new injury, so it's a new problem.

    Same thing happens in a family practice or pediatrician's office. Patient presents with a URI in Feb 2008. When the same patient comes in with a URI in Nov 2009 it's a new problem again (even though it's an established patient).

    F Tessa Bartels, CPC, CEMC

  7. Default
    Thank you. That is what I thought but started second quessing myself.

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