Wiki Can it be coded?

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torresreb

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An annual wellness visit ...

I understand the ROS cannot be coded as it is the patient's impressions and needs to be verified by the provider in order to code it ...

my question ...

in the physical exam the provider states:

"patient states left side weakness"

My opinion is that this is not enough to code ... because there isn't a 'plan' as to what will be done or what the patient should do or am I looking for too much here?

This doesn't sound like is a verification rather a repeat of what the patient said during the ROS check ...

Can the left side weakness be coded?

thank you ...
 
don't code it. The provider did not make a definitive diagnosis and patient reported diagnoses are not codeable. There are guidelines for coding hemiparesis vs. weakness as well.
 
Sounds like it could be copy-paste error. you can always query the provider and have them amend the medical record if they physically examined the patient and came to the same finding. Although if they gave a separate definitive diagnosis and weakness is a symptom you will only code the definitive DX and not the symptom
 
no copy and paste as it was hand written but I would think if the provider would verify the issue the words "patient states" wouldn't be part of the verification.. those words are what concerned me.

Also can anyone answer the following question....

if there is indeed a condition noted in the PE will an assessment and plan be required in order to code it?

for instance:

Extremities: bilateral extremity varicosity

would that be enough to code?
 
Weakness clearly fall under nervous system examination,but in your sentence "patient said that", that clearly says its not P/E, its fall in ROS. check the Dx whether he mentioned anything like stroke,nerve injury,multiple sclerosis.

second one you can code varicosity bilaterall

hope this will help you
thanks and Regards
 
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