Primary Care Coding Alert

Question: The doctor dictates a detail in his "plan" that he doesn't mention in his review of systems (ROS) or past family social history (PFSH). Can I still use the note to credit the appropriate section, either ROS or PFSH?

Delaware Subscriber

Answer: Yes. Although using a standard form, such as SOAPM (subjective, objective, assessment, plan, management), makes finding information in a note easier for any reviewer -- be it coder, insurance adjudicator, or auditor -- physicians may take notes in any format that they find appropriate provided it is legible and coherent.

Example: A note under the plan indicates "FU if fatigue continues," but the ROS does not indicate fatigue. You could count the fatigue -- which the physician may not have initially inquired about -- under ROS.