Wiki f/u xray results

[CodingMari]

I am new to coding, i am wondering how to level an e/m with chief complaint "X-Ray Results" Is this HPI under context?

 

[CodingKing]

It doesnt sound like it. I found the following on a RAC audit page

https://www.racmonitor.com/e-m-auditing-defining-the-hpi

Context: Context is most commonly defined as “what was the patient doing when he or she began having the problem.” When teaching, I usually use a silly example such as “her pain began when she fell off the ladder, which was propped up against a tree.”Such statements may seem overly obvious, but they demonstrate the point. Remember that factors present before or after the problem can support context as well. HPI should include symptoms the patient is experiencing due to his or her chief complaint. Therefore, we commonly note that negative findings in the HPI are truly ROS and not HPI, but there is an exception to this: no known injury or accident. If the patient had an injury or accident, then the severity of the encounter may shift in complexity.

 

[CodingMari]

It doesnt sound like it. I found the following on a RAC audit page

https://www.racmonitor.com/e-m-auditing-defining-the-hpi

I was viewing a chart and all it had was following up on XRAY.(wish I had chart in front to share the details, I do have on hand what you share I appreciate the feed back.

 

[1formissy]

I audit E/M services and follow up for a X-ray does not warrant a medically necessary E/M visit.

 

[saket1577]

Hi,

You can level the chart . According to scoring of History , Exam and Minimal Risk .

 

[CodingKing]

Hi,

You can level the chart . According to scoring of History , Exam and Minimal Risk .

If the result requires additional follow-up. Medical necessity is key. negative results and those that do not require follow-up can be done with a quick call from the receptionist or possibly an MA or a letter.