tci ED Coding & Reimbursement Alert - 2000 Issue 7

Patient History Can Boost Level of Service

Nugget: ED physicians and staff should be encouraged to document history with: history of present illness, past family and social history, and review of systems portion of the patient exam to increase the level of decision-making needed to optimize reimbursement. The new rules that instruct facility coders to record signs and symptoms on the UB-92 form have opened the door to more accurate reflection of hospital services. This rule will require coders to make even more use of the patient history. Since the history portion of the patient encounter is the only place where a coder can find information...

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