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Hospital visits

  1. Default Hospital visits
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    Hello: I am a physician working as a Hospitalist. I also have an interest in coding and studying for the CEMC exam.

    My questions to the experts here are:

    1. For CC is it okay if I state "f/u HTN" or "F/u anemia" ? Since I see only inpatients I am always the one initiating the visit and not the other way around.

    2. I am having difficulty with the 1995 GL regarding the physical exam. They seem too vague. Here is one of my standard f/u visit exams:

    vs: 99 f 80 135/70 100% RA
    NAD, CTA Bilateral, no increase WOB, RRR, abd: soft NT bs+, no c/c (clubbing or cyanosis) and no LE edema.

    of course, this is just an example. Sometimes I add more if there is important findings. So would you say this is an expanded problem focus or detailed exam if you were reviewing it. To me it would be a detailed based on 1995 but an EPF with the 1997. Any help is always appreciated.


  2. #2
    Your chief complaint is fine, just make sure you put one on every day you see the patient.

    I agree on your exam, detailed based on 95 and expanded problem focused based on 97.

    Laura, CPC, CPMA, CEMC

  3. Default
    Thank you, Laura. It's good to know. I try to stay as compliant as I can and review most if not all of my notes in real time to determine my own level of service.

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