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    E&M Coding from the American Medical News

    American Medical News is the print and online news publication for physicians published by the American Medical Association. No other single publication covers the same spectrum of medical news. It has a large national circulation that cuts across geographic regions, practice settings and medical specialties.

    American Medical News' forte is delivering news about the medical profession not found in other publications. Physicians read American Medical News for its timely and accurate political/regulatory coverage and information on the medical profession, public health, the medical marketplace and practice management. Regular coverage includes such topics as ethics, practice trends and legal issues.

    E&M Coding Articles

    Documentation tip: The Chief Complaint cannot be inferred.

    The outpatient note must stand alone for billing purposes; reviewers will not refer to prior documentation for a chief complaint. The following are examples of documentation that are not considered Chief Complaints.

    Q: Patient here for follow-up visit (for what?)
    Q: Patient here for second injection (what condition is being treated?)

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    Coding Tip:   What, When, Where, Why, How

    History of Present Illness (HPI ) – some sample illustrative questions:

    Location: What or where does it hurt?
    Severity: How painful on a scale of 1 to 10? Is it worse than other pains experienced?
    Timing: When did it start? One day or one week ago? What times during the day does it hurt?
    Duration: How long have you had this problem? How long does the pain last?
    Context: When did the symptoms begin? Is there an activity that increases pain?
    Modifying Factors: What have you done to relieve the pain? What are the results?
    Associated Signs or Symptoms: What are the signs – sensations, feelings, discomfort? What are the Symptoms – Are there noticeable physical presentations - lump, cut or bruise, murmur or friction rub?

    So what’s the difference between HPI and Review Of Systems (ROS)?

    Good question!

    The ROS is the inventory of body systems through questions to help identify signs and/or symptoms related to the HPI. Simply put the ROS are the questions you ask based on the information given by the patient in the HPI.

    ROS is the Achilles Heel of most encounters. And it’s not because these questions are not being asked it’s just that they are not being documented. What’s required to get “credit” for a ROS is documentation of pertinent positives and negatives as well as noting negative responses to questions asked. You do not need to list all the questions asked, only comment on the findings (i.e. GI, GU, Integumentary are negative) (www.TheCodingCenter.org)


    2010 CPT Code Changes


    Evaluation & Management Services Guide (CMS-July 2009)
    1997 E/M Documentation Guidelines
    1995 E/M Documentation Guidelines
    E/M Pocket Guide (Trailblazer Health: 2008)

    History Documentation

    Documenting a History (Tulane University Medical Group)
    Highmark Medicare Services HPI Elements (Reviewed 05/13/08)


    Highmark Medicare Services FAQ (Reviewed 2/13/2008)
    Wisconsin Medical Society FAQ (2008)
    Medicare Physician Guide (CMS-July 2007)
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