Internal Medicine 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.
Internal Medicine Coding Alert
- Don't Skip a Beat When You Report 93015-93018
Here's why 'component coding' is key If you report cardiovascular stress tests (93015-93018), make sure [...] - You Be the Coder:
Nursing Home Discharge
Question: How should we bill for a nursing home discharge after the patient has died? [...] - News You Can Use:
What the 2005 Fee Schedule Means for IM Offices
Good news: Your internist won't see the expected 3.3 percent pay cut This year, your [...] - Clip and Save:
Skip Modifiers When You Report Stress Tests
Let the CPT definitions be your guide to component coding If you're tempted to attach modifier [...] - Fee Schedule Update:
How Coders Can Welcome 'New' Medicare Visits
We've got the scoop on the latest guidelines for preventive care and EKGs By now [...] - What You Need to End Your Biopsy-Shaving Confusion
Test yourself on everyday biopsy and excision dilemmas Even though your internist documented a "punch [...] - Reader Questions:
2nd-Degree Burn Code Is a 1st-Degree Mistake
Question: The physician diagnosed a patient with a second-degree burn on her right palm (944.25). [...] - Reader Questions:
Expect Different Policies for Oximetry Coverage
Question: Under what circumstances will insurers reimburse 94760? Can we report this code with other [...] - Reader Questions:
Don't Risk E/M Payment When Prescribing Drugs
Question: The internist was going to prescribe Methotrexate and Remicade, which would require intensive monitoring [...] - Reader Questions:
When CPR May Equal Critical Care
Question: Can the internist charge 92950 (Cardiopulmonary resuscitation [e.g., in cardiac arrest]) for running the [...] - Reader Questions:
Count the Number of Immunotherapy Injections
Question: When should I report 95115 instead of 95117? What other codes are applicable?
Tennessee Subscriber
Answer: [...] - Reader Questions:
Understand Teaching Physician Exceptions
Question: My internist works at a teaching hospital, and I've heard about a "primary-care exception." [...] - 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 [...]
