Angela Schwarzkopf
Guest
Question -
There has been some debate on two items relating to E/M coding and I would love feedback that may help me to not only educate myself but my physicians and colleagues...
1. Medical Decision Making - we utilize the 1999 Table of Risk - but there is some debate in determining what medications constitute a level 3 vice a level 4 for complexity (I am speaking in terms of established patients in this instance). If a pt has hx of URI's and is in the office today with another and we prescribe an antibiotic, albuterol inhaler and motrin for fever and pain - the exam is a 3 but the history is a 4 (almost a 5) - which way do you sway with MDM??
2. If a patients past (active) medical history is documented in PFSH on a SOAP note - (i.e. pt has DM; CAD; HTN) but the physician is managing a complaint of chest pain and doesn't manage medications or anything pertaining to those PFSH elements - can you still use them to relieve the HPI statement? Can 3 chronic illness mentioned in PFSH only take the place of a 4+ point HPI statement????
Just looking for some opinions or even a place to find more definitive explanation of these two items....
Any thoughts, comments or insight is greatly appreciated!!
Angela N. Andersen, CPC
There has been some debate on two items relating to E/M coding and I would love feedback that may help me to not only educate myself but my physicians and colleagues...
1. Medical Decision Making - we utilize the 1999 Table of Risk - but there is some debate in determining what medications constitute a level 3 vice a level 4 for complexity (I am speaking in terms of established patients in this instance). If a pt has hx of URI's and is in the office today with another and we prescribe an antibiotic, albuterol inhaler and motrin for fever and pain - the exam is a 3 but the history is a 4 (almost a 5) - which way do you sway with MDM??
2. If a patients past (active) medical history is documented in PFSH on a SOAP note - (i.e. pt has DM; CAD; HTN) but the physician is managing a complaint of chest pain and doesn't manage medications or anything pertaining to those PFSH elements - can you still use them to relieve the HPI statement? Can 3 chronic illness mentioned in PFSH only take the place of a 4+ point HPI statement????
Just looking for some opinions or even a place to find more definitive explanation of these two items....
Any thoughts, comments or insight is greatly appreciated!!
Angela N. Andersen, CPC