Coding charts with templates
When setting up a template for the HPI, ROS and PE remember AC can track the billable points if you put a recognizable symbol in front of the section. For example here is one of my ROS templates:
ALL NEGATIVE EXCEPT IF + SIGN
*General : Fever, Sweats, Chills, Myalgias, Fatigue
*Neurological : Headache
*ENT : Ear Pain, Mouth Pain, Tooth Pain, Sore Throat, Hearing Loss, Nasal Discharge, Nasal Congestion, Hoarse Voice, Sinus Pressure
*Respiratory : SOB, Cough, Wheezing, Hemoptysis, Pleuritic Pain
*Cardiac : Chest Pain or Pressure
*GI : Abdominal Pain, Nausea, Vomiting, Diarrhea,
*Immune : Itchy Eyes, Sneezing, Swollen glands
When signing the chart off, if you use the ?E&M Coding Helper? you will see in the center the ?>? sign in a box under the title ?Select A Delimiter? and that symbol will silently be counted as your billable points for HPI, ROS & PE. Then the only thing you have to do is pick the Medical decision making level. AC picked the ?>? symbol but many people use this sign for their documentation. I used the > sign but it was pointed out how it can used in the text so I will be switching to ?*?. Here is an example of a PE:
*General: Alert, responds appropriately, NAD
*Eyes: Sclera, Conjunctiva & Lids appear normal
*Pinnae & Nose: Normal Appearance, No Mass, Not Tender
*Ears :Tympanic Membranes & EAC - normal
*Nose: Mucosa pink, no edema, no bleeding, Sinuses are not tender
*Mouth: Teeth, Gums, Lips and Tongue - Normal
*Throat: Tonsils not red or enlarged, No Exudates, Palate normal, tongue normal, Voice Normal
*Neck : No Masses, No Crepitance
*Cervical Nodes : Anterior & Posterior Cervical Nodes Normal Size and Not Tender
*Respiratory Effort : No Retractions, No Respiratory Distress, Normal Respiratory Rate
*Respiratory Auscultation: No Crackles, No Wheeze, No Rhonchi, Good Breath Sounds
*Cardiac Auscultation : RRR without Murmur
I need to make more changes to my templates but when I?m done I will put them on the web.
Please remember if you create template like this to help your coding, if you don?t do a particular point you will need to remove it so it is not counted. That could be fraudulent.
