Good Morning Alice,
The location of the documentation in the chart is unimportant. What you have to do is ascertain why the patient is there.
If he/she is there for back pain, it appears that x20 years reflects duration. If the patient is there for something else, it would seem to be reflective of a PMH. As it relates to utility of the same element (x20 years) as as two separate areas of history, some carriers have indicated that this is not permitted and that you may use it as one OR the other, giving you the discretion to decide here you put it.
I hope this helps!
Doris V. Branker, CPC, CPC-I, CEMC, CIRCC
- 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