tci Part B Insider - 2011 Issue 26

Documentation: Code Charts Properly Every Time by Nailing Down Acronyms

Would you be able to count E/M bullets properly if the physician wrote 'WBC WNL'?Sometimes physicians actually do speak in "code" -- by using specialized acronyms that they may have learned in medical school--or sometimes, that they've made up on their own. But if you can't differentiate between the terms they write down in their charts, your coding may suffer.Here's why: When the physician documents a chart, he doesn't always have time to spell out phrases such as "past history" (PH) and "present illness" (PI), but knowing which is which can make a tremendous difference in the...

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