Low hanging Fruit

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.

• "Negative,""noncontributory," "not significant,"  "no significant past medical history"unknown," "reviewed in chart,"  & "Denies" are not sufficient from a billing perspective
• For a Level 5 chart, you need to document 2 of 3 elements (Past Med/Surg History, Fam History, Social History)
• Selecting "Include Medical History" pre-populates "No active or resolved past medical history items have been selected or recorded."  This does not count as a billable element.  If you have this, deselect it to make the chart easier to read.

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.