Case Study:
Are You Making the Most of
Published on Tue Jul 01, 2003
Translating coding advice into practice means whipping out the patient encounter forms and mapping theory onto real patient scenarios that cumulatively cost you valuable dollars.
The following patient history and physical examination report is fully dissected, showing you where the E/M points and money are in your physician's documentation. The report comes from James Blakeman, senior vice president of Healthcare Business Resources in Bala Cynwyd, Pa. In the physician's notes, Blakeman inserts flags that help break down the E/M components. At the beginning of the example is a key for understanding the bracketed labels that are not self-evident. Take note, however: This history and physical documentation is not perfect that would make coding too easy! Concentrate on Facts: Piece Apart E/M Documentation Follow along with this detailed analysis, and practice similarly scrutinizing other ED claims. Your hard work will lead to more precise coding that captures all the elements contributing to E/M levels. Key for Unclear Bracketed Terms:
RPPMod Presenting problem is moderate risk
NewNMMore New, non-minor problem, requiring more assessment
RS-XXXX Organ system review responses taken from patient as part of the history
Const-GA Constitutional symptoms general appearance ("development" as in "young female" counts as GA)
Const-VS vital signs
R-OptionLow Management options represent low risk
Chief Complaint: Abdominal Pain [PertComplaint] [RPPMod] [NewNMMore]
History: Patient is a 19-year-old female who presents to the ED with a chief complaint of abdominal pain [NewNMMore]. The pain had started about two days prior to her evaluation [Duration] and was worse in the morning [Timing]. The pain had increased in severity the morning of admission to the department and was described as moderate [Severity]. The pain was bilateral and lower in the abdominal area [Location]. The patient had nausea [Assoc Symp] and two episodes of vomiting [Assoc Symp, which you count only once toward the history of present illness (HPI), either here or previously or later in the paragraph].
She denied any urinary difficulties [RS-GU] or bowel symptoms [RS-GI]. She had recently noted abnormal menstrual periods of the last two or three months [Assoc Symp and RS-GU]. She also noted an occasional or intermittent vaginal discharge [Assoc Symp, RS-GU]. She also admitted to being sexually active with no form of birth control being used [Soc]. She had no other significant past medical history [Pmed]
Physical Exam: The patient appeared as a young female [Const-GA] with a complaint of severe lower abdominal pain. The patient's temperature was 100.5 degrees, blood pressure was 105/60, pulse was 82, and respiratory rate was 26 [Const-VS]. Physical examination of the patient revealed unremarkable cardiac [Cva-Neg] and chest exam [Che-Neg]. Abdominal exam revealed a soft abdomen [GI-Pal] with decreased bowel sounds [GI-Aus]. The patient exhibited bilateral lower abdominal pain to deep palpation [GI-Pal]. The [...]
