Wiki Re: Counting Physical Examination

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Re: Counting Physical Examination

A hospital in our area has a special program were they bill for us and reimburse us out of a special fund that they have for people without insurance.

Our doctor mentioned in her consult report that the patient had a well-healed scar on her abdomen, and also stated that the patient was an alert and oriented woman who appears comfortable.

They gave her credit for vital signs for the constitutional system, and felt that the alert and oriented statement should also be credited toward the constitutional area because she did not use the words alert and oriented to time and place.

They use the 95 rules for coding.

I had thought that the statement alert and oriented should be used for a psych credit, and that the well-healed scar statement could be used for the integumentary system.

We were billed a lesser code because of this.

I would appreciate any opinions.

Thanks,

Dee
 
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