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Orthopedic Coding Alert

Auditing:

Check Your HPI, Risk IQ With Pre-op Exam Case Study

Published on Thu Jul 01, 2010

Hint: Your orthopedist's recs are the ones to count under mgt options.When a patient needs preoperative clearance for a major surgery, don't scratch your head over the applicable table of risk selections -- focus on your doc's role.Test your major versus emergency surgery savvy and who gets the credit for surgical recommendations with this real world case.A 45-year-old patient fell from a ladder, hit a fence on the way down, and fractured his elbow. A surgeon is taking patient to surgery for an open reduction of the fracture and has asked my physician to evaluate the patient for pre-operative clearance.My physician clears the patient, who has no identified risk factors for surgery. The surgeon takes the patient into the OR in the following 24 hours. Regarding my physician's E/M, I have two auditing questions:1. Do Details Count as HPI?Should you count the accident's details ("on a ladder," "hit a fence") as [...]
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