Home Forums Discussions Coding and Billing Coding and EMR's

I am new to AC and not very knowledgeable about coding. I would appreciate some guidance. With coding the complexity rises if we document PFSH elements. With AC the PFSH are present with each note. Does this count? Do I have to document that PFSH was reviewed?

Yes, it counts, but it being there in your note I think implies it was in some way reviewed. I'd give a general review with the patient, even as simple as "anything change" or "any luck giving up the tobacco?"... otherwise you find notes with info out of date, like a chart I had that showed one patient apparently was in 6th grade for a few years (she wasn't, I just forgot to change the 6 to 7 and now about to be 8th grade)

Thanks. I realize I need to do a little CME on coding. Not my favorite subject.

Yes, keeping things UTD is tedious. Sometimes medical assistant forgets to delete the Zpak they got put on and it looks like they've been on it for months. It's too bad there isn't some way for time limited rx to automatically remove themselves from the med list.

John,
I strongly recommend you look into EMUniversity.com to get yourself educated about coding. You can start with their FREE 2hr CME session at https://learn.emuniversity.com/course/category.php?id=4
Good Luck,
David

I'm interested in how many of you do your own coding for a billing company to send out, how many allow the billing company to do everything, and how many use the AC billing.

David,

I watched the E/M University basic video--terrific. Where was this when I needed it 15 years ago! We've been using one code for hospital visits, one code for nursing home visits and are probably doing all sorts of other innocently stupid coding things. I wonder how many thousands of dollars we've lost as a result. Thank God we haven't been audited!

Question--how can I get my staff to help with coding issues? I know I need to get up to speed, but what can I delegate?