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E/M guidelines

  1. Default E/M guidelines
    Medical Coding Books
    Ongoing discussion with other coders/auditors here:

    If you find items of history or exam or MDM in areas not specified as such do you count them? For example if you find elements of history in the Assessment/Plan, do you count them?

  2. #2
    Location
    Kansas City, MO
    Posts
    431
    Default
    Absolutely. I use everything I can regardless of what section it is or what "heading" it is under. I just make sure not to double dip.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC
    PMCC Licensed Instructor
    Kansas City, MO Chapter
    President, 2018
    Vice President, 2017
    Member Development Officer 2016
    Harrisonville, MO Chapter President - 2013
    ICD-10 Education Coordinator- 2012
    Chapter President - 2011
    President Elect - 2010

  3. #3
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    yes, sure do! It doesn't matter "where" it's located, not all doc's even dictated in the same format... some just have one large paragraph, all in one!!

    but as LindaEV stated -- NO DOUBLE DIPPING!!
    Donna, CPC, CPC-H

  4. Default
    Hi,

    Yes i too agree.You can count anywhere from the document, but no double dipping..

    Nalini CPC

  5. #5
    Location
    Ellenville, New York
    Posts
    1,176
    Default Not always labeled as such
    Keep in mind that not all physicians will have the history, exam and MDM labeled as such (especially history items) so only being allowed to use items that are labled would be too restrictive.

    Lance Smith, MPA, COC, CPMA, CEMC, RHIT, CCS-P, CHC, CHPC

    Director, Health Information Management
    HealthAlliance of the Hudson Valley
    Kingston, NY


    2016 Secretary
    Ellenville, NY Local Chapter

  6. #6
    Default
    I have to disagree with pulling HPI elements from the A&P. I don't really care what headers are used so that doesn't matter, but once you start telling me your assessment you are done getting HPI as far as I'm concerned.

    Laura, CPC, CPMA, CEMC

  7. Default
    I posted this same question on the EM University website, and this was the answer I received from Dr. Peter Jensen. Lots of different opinions.

    Just an FYI....

    Username: pjensen
    Message:
    I think you can take some elements of history, such as items in the HPI which can also be used in the ROS, but some carriers consider this double-dipping and do not allow it. Check with your own carrier. As far as elements of history from the MDM, I do not think you can do this. I think what youare saying is, if in the assessment and plan, the doc describes a problem as stable, can I use this statement to help complete the HPI based on the "status of chronic or inactive problems." I don't think you can do this. My advice is to have doctors "surrender" and structure the note so that there all three key components can stand alone. Any other approach is simply too risky.

    PJ

  8. #8
    Default
    Quote Originally Posted by pattywright View Post
    I posted this same question on the EM University website, and this was the answer I received from Dr. Peter Jensen. Lots of different opinions.

    Just an FYI....

    Username: pjensen
    Message:
    I think you can take some elements of history, such as items in the HPI which can also be used in the ROS, but some carriers consider this double-dipping and do not allow it. Check with your own carrier. As far as elements of history from the MDM, I do not think you can do this. I think what youare saying is, if in the assessment and plan, the doc describes a problem as stable, can I use this statement to help complete the HPI based on the "status of chronic or inactive problems." I don't think you can do this. My advice is to have doctors "surrender" and structure the note so that there all three key components can stand alone. Any other approach is simply too risky.

    PJ
    I like what Dr. Jensen has stated " check with your carrier" at times when I'm doing his "case of the week" I get a differant level than he because I am following my MAC guidelines. The best thing to do in these cases is to consult with your carrier, as only they can tell you what they accept and do not accept.

    Best of luck!
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  9. #9
    Location
    Dover Seacoast New Hampshire
    Posts
    1,970
    Default
    I agree with Dr. Jensen about not using the status of the assessment "stable, chronic, improved" as part of the HPI. So for example, if you see Type II Diabetes, Uncontrolled as your assessment, I wouldn't use "uncontrolled" as a history element.

    But there are times you'll find history components in the assessment....

    For example, I have a hosptialist whose notes often ramble on and on....and within his assessment, he's still documenting history elements. For example, he might say something like , "I am going to increase insulin again because the fasting BG levels have continuously increased since last month when he saw his primary care physician".


    Additionally, I often see this in the MS exam: "Considerable pain with flexion, extension and rotation of hips. Patient describes pain as 8 out of 10." That comment is not objective...it's subjective and qualifies for a severity bullet.

    If E&M coding was easy and convenient, all providers would list all history, review, exam and assessment verbiage under the proper headings. But not all providers were trained in the same way, others are more verbal and explanatory, so I always use the entire note to support the elements of the key components. As long as you don't use the same information twice, are reasonable in what you give credit for, and would feel comfortable defending yourself in an audit, then I would use the documentation where you find it. E&M Coding is not really an exact science, it's more of an art....

    You'll find that an EHR is making this a lot easier for coders. The elements are right where they need to be. The problem now,is that the docs get click happy and over-document.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  10. #10
    Location
    Milwaukee WI
    Posts
    4,466
    Default Agree w/ Pam Brooks
    Excellent examples, Pam ... and I totally agree.

    F Tessa Bartels, CPC, CEMC

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