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Primary Care Coding Alert

Auditing:

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

Published on Fri Jun 04, 2010

Hint: Your FP'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. Ortho 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. Ortho 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 context [...]
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