For the PFSH if the provider states "the patients past, medical, surgical, social and family history was reviewed and confirmed with the patient and are unchanged from the previous notes" he must state where this previous note is located and the date of it, so that if audited you can provide this information ( also when you audit) this note you should be looking for that specific date of service and make sure these items are "documented".
As for the exam - you cannot use that the provider must document an exam for this visit. I'd like to know what the patients chief complaint / reason for this visit is. If this is an established pt you only need 2 of the 3 key components ( just keep that in mind).
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join