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Bullets for E&M

  1. Default Bullets for E&M
    Medical Coding Books
    Opinions please on how many bullets you see!

    No specific CC is listed

    HPI: Patient is a 33 y/o male, s/p assault with positive loss of consciousness who was brought to the ER with a right sided scalp laceration which was staples in ER. Ct of head shows linear nondisplaced parietal skull fx with small amount of intracranial air. No reported seizure ativity or mental status changes.

    Mary

  2. #2
    Default
    Bullets for an Exam?

    Is this the whole note?

    Is this a new or established patient, consult or other?

    Shown as is:

    HPI: Patient is a 33 y/o male, s/p assault with positive loss of consciousness who was brought to the ER with a right sided scalp laceration which was staples in ER. Ct of head shows linear nondisplaced parietal skull fx with small amount of intracranial air. No reported seizure ativity or mental status changes.

    CC: I would use s/p assault w/ + loss of consciousness
    HPI: Location - right sided scalp lac
    ROS: (2) you could use no seizures (neuro) no mental status changes (psych)
    PFSH: none
    Problem Focused History

    Exam: None

    MDM:
    New problem, no work up (that I can tell)
    Review CT
    Acute Complicated Injury - Moderate Risk

    What do you think?
    Last edited by ARCPC9491; 10-02-2008 at 12:11 PM.

  3. Default
    This is an H & P for hospital and I was questioning the bullets for the cc and hpi portion only. Sorry for confusion
    Mary

  4. #4
    Default
    I see - well I get :

    CC: I would use s/p assault w/ + loss of consciousness
    HPI: Location - right sided scalp lac


    For the lowest level for an admit H&P, you need to have a detailed history - which the documentation you have provided does not support a detailed history

  5. #5
    Location
    Milwaukee WI
    Posts
    4,466
    Default Is the ROS & PMFSH separate?
    I'm going to assume that ROS and PMFSH are separately recorded.

    I'm really stretching for this, but ...

    CC: S/p assault w/ LOC
    HPI: location (rt scalp, skull), quality (nondisplaced FX), severity (small amount of air), Assoc Signs (no seizure activity)

    If the doc had only said WHEN the assault occured, you'd clearly have duration.

    F Tessa Bartels, CPC, CPC-E/M

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