History Documentation Quiz Answers
1. C. Physician
Only the physician is allowed to take the HPI.
2. D. All of the above
The nurse, physician, or the patient can fill out a questionnaire prior to the visit. The physician must document that he or she reviewed the ROS with the patient.
3. B. Whenever there is new information, otherwise it is permissible to refer back to the original documentation of the information
The PFSH has to be updated only if there is new information. It is permissible to state “no updates since original documentation.”
4. A. True
A chief complaint must be documented for every visit. Some carriers will deny the claim for not meeting medical necessity if it is not documented.
5. B. No
There must a description of what the follow-up is for (e.g., rheumatoid arthritis, osteoporosis).
For questions or information on proper coding and documentation, contact Melesia Tillman, CPC, CPC-I, CRHC, CHA, at mtillman@rheumatology.org or (404) 633-3777 x820.
Coding Update
Oct. 1, 2014 will mark a new era of coding for diagnoses. That’s when the healthcare industry is slated to convert from ICD-9 to ICD-10. The ACR practice management department is dedicated to preparing rheumatology practices for the change. Contact Melesia Tillman at mtillman@rheumatology.org for a training session near you.