Another word on Past Medical & Surgical History, Family History, Social History:
One of the most likely places to get down coded is in this section of your chart. I've outlined the numbers before, but overlooking this portion of the chart is EASY to do. Over the past 2 months, I've seen this section be improperly documented on almost every single shift by all level EM residents.
Acceptable phrases include "Denies Past Medical History" & "No Past Medical History"
High Acuity Caveat will allow you to use the phrase "Unknown" however your chart has to clearly describe why High Acuity Caveat applies and why you were unable to obtain these historical elements.
REMEMBER: Coders can only bill for services that are provided AND documented.
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.