tci Part B Insider - 2003 Issue 34

History: Make Sense of a Single Paragraph

Learn to dissect jumbled history into three categoriesMany coders expect the physician to separate notes carefully into history of present illness, review of systems, and past family and social history to make it easier for them to construct the documentation.  But that's not how physicians are trained to take a history, and coders should be used to sorting information into the three categories themselves, says Joanne Steigerwald, senior consultant with the Wellington Group in Cleveland.  "Most coders and auditors would like it in nice separate paragraphs,"  Steigerwald says. "It not only isn't going to happen, it...

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