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CC and A&P

  1. Question CC and A&P
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    We have this scenerio all the time: Patient comes in complains of runny nose and backache. He also has HTN, DM, Gout. etc.

    DM- stable. no change in meds.
    HTN- stable. no change in meds.
    Gout- order labs.

    f/u 3 months or sooner.

    So my question is since the provider never addressed the runny nose or backache do you still code them?

    Any help is appreciated!!!

  2. #2
    Hello there,

    I would not code for the runny nose or backpain, because the provider did not address it in the documentation or the A/P.
    I would, however, ask the provider if he did address the runny nose and backpain, assess and manage it with any type medication, or referred the patient possibly to a specialist for the backpain.
    This could boost his E&M and reimbursement and cover him/her to address what the patient came in to see him/her for in the beginning.

    Hope this helps,

    The Oracle

  3. Default
    Thank you! You're the only one who answered me

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