Coding, Chart Documentation and Reimbursement - Thurston ...
Coding, Chart Documentation and Reimbursement - Thurston ...
Coding, Chart Documentation and Reimbursement - Thurston ...
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<strong>Coding</strong>, <strong>Chart</strong> <strong>Documentation</strong> <strong>and</strong><br />
<strong>Reimbursement</strong><br />
Common E/M Service <strong>Documentation</strong><br />
Errors –History<br />
• Documenting status of Chronic Conditions<br />
must provide a description of the condition.<br />
• Inappropriate to list the condition with just a<br />
status of “stable”.<br />
Example:<br />
• HPI: 1) HTN, pressures running in the 130s, no<br />
dizziness; salt intake down.<br />
• 2) Dyslipidemia, exercises daily, still taking red rice<br />
yeast extract, no muscle aches.<br />
• 3) COPD, using inhaler PRN, wheeze reduced<br />
w/recent jogging.<br />
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