tci ED Coding & Reimbursement Alert - 2017 Issue 5

You Be the Coder: Who can Record the PFSH?

Question: Our ED record pulls information such as this from nursing documentation: Past Medical History (As documented by Nursing): Angina, Hypertension, Stents, Other: elevated cholesterol; Other: emphysema on PET scan;Other: diabetic neuropathies; Arthritis, Back pain, Fractures of lower extremities,Fractures of upper extremities; Diabetes Type II, Other: had been on metformin-but has been taken off; Constipation; Cataract, Other: reading glasses; Lung cancer, Skin cancer, Other: right ear; Measles, Mumps, Varicella (Chicken Pox); Herpes zoster, Other: has had shingles vaccinePast Hospitalizations and/or Surgeries: No documentation per Nursing. Family History Both parents deceased, Father from heart disease, Mother from cancer...

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