A thorough read is all it takes to identify the most glaring issue.
Sometimes, we’re so quick to review a physician’s documentation that we can gloss over important facts within the records, which can lead to assigning the wrong code. Read through the following documentation example and see if you can identify the problems with the physician’s code assignment.
Date of service: Dec. 8, 2014
Chief complaint: The patient presents today to assess the status of his left shoulder abscess, on which we performed an I&D on Dec. 1.
HPI: This 77-year-old male is improving with no further problems and there are no stitches that need to be removed. He is back to his normal activities of daily living and his urination and bowel movements are normal. He is not using pain medication and he reports that the incision is healing well. He has a visiting nurse that packs...
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