# Just curious!



## mlemon (Dec 12, 2008)

I have just recently began coding the E/M visits for our practice.  The lady who did this position before me was NOT a certified coder.  **Let me say...for those who are not certified...I am in no way saying that someone who is not certified does not know how to correctly code** With that being said....coding in the practice had just been handed down through the years person to person, with no good training involved.  I also just recently found out that the phyisicans were given a "cheat sheet" on coding in order to get a high level visit coded.  I am going through this "cheat sheet" and also doing an audit of E/M services being dictated.  

I would like everyone's opinion on a couple of key sentences that are being used by a good bit of our physicians.  I would like all feedback...whether you agree with what is being done or not.  

Here it goes:

{Her past history, social history, and family history have not changed within the last 2 months.}

Who considers this adequate requirements for a complete PFSH?

{The ten-point system review is negative}

Who considers this a complete ten-system review?

These two sentences are used a good bit for the history portion of the dictation.  I would just like some feedback on this issue......

Thanks in advance!


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## LLovett (Dec 12, 2008)

I don't agree with those and would not give credit.

In order to use information from another source, ie previous note, you have to identify it by name and date.

What 10 systems were reviewed? There are 14 total recognized by medicare. Currently they still get credit for statements like "All systems reviewed and negative except for as noted in HPI". I am teaching my providers to not do that and to actually list each system they reviewed.

Good luck breaking bad habits,

Laura, CPC


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## cdcpc (Dec 16, 2008)

*I agree with Katmyrn...*

I would not count the first statement as a complete PFSH.  If this physician stated "reviewed past family and social history from so and so date and all have remained the same" I MIGHT think about giving credit, but only if the referenced source is a truly comprehensive PFSH.  
Also, for ROS, the physican must state what systems were reviewed and if the review resulted in negative or pertinent results.  For instance, I would credit this as a complete ROS:
eyes-negative 
ENT-negative
cardiovascular-positive for chest pain
respiratory-negative
Gastrointestinal- positive for abdominal pain
Genitourinary- negative
Musculoskeletal-negative
Neuro-negative
Psych-negative
Ingetumentary-negative

Good luck!  I've found that if you take the time to educate a physician WHY it must be documented in a certain way, they will be more likely to pick up on the good habit.  Also, encourage them when you see the documentation change in good ways. 



mlemon said:


> I have just recently began coding the E/M visits for our practice.  The lady who did this position before me was NOT a certified coder.  **Let me say...for those who are not certified...I am in no way saying that someone who is not certified does not know how to correctly code** With that being said....coding in the practice had just been handed down through the years person to person, with no good training involved.  I also just recently found out that the phyisicans were given a "cheat sheet" on coding in order to get a high level visit coded.  I am going through this "cheat sheet" and also doing an audit of E/M services being dictated.
> 
> I would like everyone's opinion on a couple of key sentences that are being used by a good bit of our physicians.  I would like all feedback...whether you agree with what is being done or not.
> 
> ...


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