review of systems and physical exam documentation question

[James ij]

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Is it 10 or 12 systems for a level 4 visit? I just need to clarify, cause this I am hearing mixed responses

 

[gutonc]

Is it 10 or 12 systems for a level 4 visit? I just need to clarify, cause this I am hearing mixed responses

Since you're "Pre-health", I can't imagine that this actually matters to you.

But assuming it does matter, have you considered asking the Googelz? Or just documenting 13 systems and being done with it?

 

[bananas85]

On a similar note, how do people document this inpatient, and outpatient to get the highest level of billing without committing fraud. I have seen all extremes from people completely not asking but just assuming and documenting " a complete 9 point ROS was performed and negative except mentioned in HPI" to "actually sitting there and asking individually do you have headache, do you have etc.."

 

[gutonc]

On a similar note, how do people document this inpatient, and outpatient to get the highest level of billing without committing fraud. I have seen all extremes from people completely not asking but just assuming and documenting " a complete 9 point ROS was performed and negative except mentioned in HPI" to "actually sitting there and asking individually do you have headache, do you have etc.."

I have a form that each patient gets that covers 13 systems. I scan it into the chart. I document things in my note that actually matter.

 

[thehundredthone]

I have a form that each patient gets that covers 13 systems. I scan it into the chart. I document things in my note that actually matter.

I've seen this in some clinics. Though it makes me wonder that patients can't just claim (if they so felt) that they didn't really understand what it meant to say. Do you redirect your encounter based on what does and does not get ticked?

 

[gutonc]

I've seen this in some clinics. Though it makes me wonder that patients can't just claim (if they so felt) that they didn't really understand what it meant to say. Do you redirect your encounter based on what does and does not get ticked?

I use this for billing purposes only. I actually ask what they're there for and direct my questions appropriately.

 

[bananas85]

I understand why you have to do that, but when the roles are reversed and I have a doctors visit, the forms feel like such a waste of my time and useless. I wish they would change the way things are allowed to be billed.

 

[gutonc]

I understand why you have to do that, but when the roles are reversed and I have a doctors visit, the forms feel like such a waste of my time and useless. I wish they would change the way things are allowed to be billed.

That form takes 15 seconds if you know how to read.

Good luck on changing the way we get paid though.