I'm going to ask a stupid question (I've only been doing E/M for a couple months on the job, and I'm first coder here), because for some reason this isn't entirely obvious to me. I have an MD who did an inpatient consult, and then did a "followup" of patient in the SNF 2 weeks later. Do I code second visit as inital SNF visit because it's a different POS, or do I code as subsequent SNF visit?

Please answer another question: I'm starting to audit E/M documentation, and one MD mixes body areas and organ systems in his exam notes. The internet is full of what seems like differing opinions. Should I request he use one or the other to cover the documentation? Or can we pull systems from the body areas, such as "NECK: NO JVD OR ADENOPATHY", and count it as cardio and hem/lymph?
THANKS for any assistance!