Results 1 to 3 of 3

Documentation questions

  1. #1
    Default Documentation questions
    Exam Training Packages
    I have quite a few questions:

    1.) When using the 1995 Examinatino guidelines, do the vitals need to be included to count toward constitutional? Or can they get credit for only mentioning the general appearance?

    2.) If the chief complaint is documented separately from the HPI, can you count that toward Location or other elements if they are not listed in the HPI? For Example:

    CC: Abdominal Pain

    HPI: Patient states she feels better. (this doesn't tell me where the pain is located, so can I use abdominal toward location?)

    3.) In the MDM, do you count the problems that the physicians are NOT managing?

    4.) When Psychiatric is being used in part of the PFSHx, can I use that toward psych in the review of systems? For example:

    *Past Medical History: COPD, emphysema, tremors
    *Past surgical : Tubal ligation
    Allergies: Ibuprofen
    Medications: Tylenol and Codeine
    Psychiatric: History of anxiety, posttraumatic stress disorders.


    Thank you,
    Tiffany Fischer, CPC, CEMC

  2. #2
    Default
    Hi Please see my responses highlighted below,

    Hope this helps you,

    Thank You,

    Purnima S

    Quote Originally Posted by tfischer View Post
    I have quite a few questions:

    1.) When using the 1995 Examinatino guidelines, do the vitals need to be included to count toward constitutional? Or can they get credit for only mentioning the general appearance? -
    Ans: Yes - We count Vitals in Constitutional, as per our hospital coding specifics.[/COLOR]

    2.) If the chief complaint is documented separately from the HPI, can you count that toward Location or other elements if they are not listed in the HPI? For Example:

    CC: Abdominal Pain

    HPI: Patient states she feels better. (this doesn't tell me where the pain is located, so can I use abdominal toward location?)
    Ans: -This is applicable, we can still count location or other HPI elements from CC

    3.) In the MDM, do you count the problems that the physicians are NOT managing?

    4.) When Psychiatric is being used in part of the PFSHx, can I use that toward psych in the review of systems? For example:

    *Past Medical History: COPD, emphysema, tremors
    *Past surgical : Tubal ligation
    Allergies: Ibuprofen
    Medications: Tylenol and Codeine
    Psychiatric: History of anxiety, posttraumatic stress disorders.

    Ans: No we dont count ROS from PFSH

    Thank you,

  3. Default
    4) " When Psychiatric is being used in part of the PFSHx, can I use that toward psych in the review of systems? For example:

    *Past Medical History: COPD, emphysema, tremors
    *Past surgical : Tubal ligation
    Allergies: Ibuprofen
    Medications: Tylenol and Codeine
    Psychiatric: History of anxiety, posttraumatic stress disorders.

    Ans: No we dont count ROS from PFSH" From Purnima.

    I do not agree with this answer because: for (eg) all these are important for the current case under discussion- Abdominal pain
    (Eg) past surgical- Tubal ligation; this is vitally important to rule out whether she is having Ectopic Pregnancy and may/ might have gone for rupture ectopic, irrespective of knowing her LMP from the history.
    Tylenol codeine can produce abdominal pain too (gastritis; even gastric perforation and internal bleeding)
    Psy: history of anxiety ,PTD can also be a cause of abdominal pain with the ANS invovlment.
    So also others have impact on the present condition and necessitates ROS related to that.

    This just for adding up information regarding the importance of ROS for the CC, PFSH
    Last edited by preserene; 08-21-2010 at 11:20 AM.

Similar Threads

  1. CPC practice exam questions vs. CPC actual exam questions
    By kbearden1985 in forum Medical Coding General Discussion
    Replies: 12
    Last Post: 02-02-2017, 12:43 PM
  2. Documentation on correct documentation placement of procedure notes in the EMR
    By ashephard in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-25-2014, 04:36 PM
  3. Documentation questions...HELP
    By songbird4700 in forum Gastroenterology
    Replies: 2
    Last Post: 10-11-2010, 09:33 AM
  4. Questions re: documentation of Consult-E/M
    By AmyLitterell in forum Auditing General Discussion
    Replies: 1
    Last Post: 07-02-2010, 04:55 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.