General Surgery Coding Alert
Let the Elements Drive Your History Documentation
Question: The chart that physicians use to select the level of history includes identifiers. For example, under the 1995 guidelines, to support a detailed level of history, documentation must contain at least four recognized elements of the history of present illness (HPI), between two and nine elements of the review of systems (ROS), and at least one element of past, family and/or social history (PFSH). Answer: You should assign the level of history according to the elements present in the physician's documentation (HPI, ROS, PFSH).
What should we do if the levels of HPI, ROS and PFSH don't match identically to the chart? How should I determine the levels?
Virginia Subscriber
In the history section, the components must meet or exceed all of the listed requirements. If the documentation is deficient in one of the elements, that element will limit the level of history supported by the note.
General Surgery Coding Alert
- 5 Steps Help You Reap Full Pay for Partial Colectomy Claims
Don't overlook associated procedures, or you'll be giving up reimbursement When reporting colectomy, chances are [...] - Clip and Save:
This Helpful Tool Adds Up to Easy Colectomy Coding
Keep score to select from 44140-44160 Here's an easy way to select among the available [...] - NCCI Quick Update:
Hundreds of Edits Limit Use of Size-Based Wound Care Codes
General surgery practices looking forward to reporting new-for-2005 size-specific wound care codes now need to [...] - Hemorrhoidopexy Brings Relief, Documentation Challenges
No more unlisted-procedure code for innovative hemorrhoid treatment To establish medical necessity for hemorrhoidopexy, make [...] - Modifiers in Action:
Related and/or Anticipated Procedures Call for -58
2 case studies illustrate the meaning of a staged procedure To use modifier -58 properly, [...] - You Be the Coder:
Do Multiple Polyps Mean Multiple Codes?
Question: Often, the surgeon will remove several polyps via colonoscopy using the same technique. Less [...] - Reader Questions:
Choose 99235 for Physician Who Examines Patient
Question: Dr. Smith was on-call and admitted a patient to the hospital. On the same [...] - Reader Questions:
Layers Don't Always Determine Repair Code
Question: How should I report repair of an irregular, 3.5-cm laceration of the chin involving [...] - Reader Questions:
Check Date When Coding Admission From ED
Question: When our surgeon admits a patient to the hospital after hours from the emergency [...] - Reader Questions:
Medicare Won't Recognize 'After-Hours' Codes
Question: Will Medicare pay extra for the surgeon seeing the patient for an unscheduled appointment [...] - Reader Questions:
Open Cholecystectomy With Cholangiogram? Here's How
Question: Which code(s) should I use to report cholecystectomy with cholangiogram and exploration of common [...] - Are You Ready to End Your E/M-Guideline Confusion? We Can Help
Use CMS' responses to our questions to report correct E/M levels Like many coders, you've [...] - You Be the Expert:
Should You Factor Patient's Status?
Question: During an office visit, my doctor performed an expanded problem-focused history, a problem-focused examination, [...] - Bonus Question:
Improve Your Prescription Drug Documentation
Find out what CMS has to say about the management options category Calculating a patient's [...] - Reader Question:
Let the Elements Drive Your History Documentation
Question: The chart that physicians use to select the level of history includes identifiers. For [...]
