possibly E&M? =(HCFA) documentation guidelines for Evaluation and Management (E and M) Services
Posted By: ltt on 2008-01-09
In Reply to: I reviewed each chart in detail as well as completed worksheets Please SM - Jenny
Subject: possibly E&M? =(HCFA) documentation guidelines for Evaluation and Management (E and M) Services
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Could it possibly be the home care services
Subject: Could it possibly be the home care services
x
documentation
Subject: documentation
subtalar arthroereisis see site:
http://blue.regence.com/trgmedpol/surgery/sur144.html
I searched for documentation --sm
Subject: I searched for documentation --sm
but was unable to find a solid form of albuterol, although I am sure that I have seen a gel like substance to be placed in a nebulizer. I know that albuterol is a crystalline powder though and is soluable in water. Perhaps that is what I was thinking. sorry for the misconception on my part. Thanks for making me aware of it.
J&C7 guidelines?
Subject: J&C7 guidelines?
J&C7 guidelines.  This is in reference to hypertension. I cannot find this in my Stedman's cardiology or on google. Any help would be appreciated. Thanks in advance.
Thanks! Where do I find their guidelines then?
Subject: Thanks! Where do I find their guidelines then?
? term "cyber" in relation to "computer/electronic chart" documentation. (sm)
Subject: ? term "cyber" in relation to "computer/electronic chart" documentation. (sm)
This is just a guess as I am not "computer savvy" in regards to tech terms.
That's why the field is in the state it is...no guidelines followed....
Subject: That's why the field is in the state it is...no guidelines followed....
everyone going by their own rules. There is no consistency. And thanks to that we're now pretty much considered non professionals IMO. I say bring on the mandatory licensing/certification to bring the professionalism back to the field!
pt taking Accutane following the guidelines set about by roe-sh nm
Subject: pt taking Accutane following the guidelines set about by roe-sh nm
d
My company guidelines have always stated...
Subject: My company guidelines have always stated...
"it is okay to leave abbreviations for diagnostic/lab tests and medication administration as abbreviations under diagnosis, name of operation, assessment/impression"
Guess you would have to go by your company rules.
I would type verbatim within the guidelines
Subject: I would type verbatim within the guidelines
of the BOS. In other words, I would not type contractions, slang, or prohibited abbreviations. If the account wants you to ignore the BOS once you get the job, that's fine, but I think it would be better to show your knowledge of the BOS and get it wrong than to disregard the BOS altogether.
please give me a book reference, not google.. i need hard copy documentation on 2 things
Subject: please give me a book reference, not google.. i need hard copy documentation on 2 things
Foxhollow device (is it Fox Hollow? Foxhollow? FoxHollow?)
silverhawk atherectomy ... (is it SilverHawk? Silverhawk? silverhawk?)
only hard copy in a book or something reputable please... Google isn't affording me the answers I need this time around. Thanks.
The guidelines that I was instructed by are "dig could be digoxin or Digitalis; leave as dig".
Subject: The guidelines that I was instructed by are "dig could be digoxin or Digitalis; leave as dig"...
ALS Emergency Services
Subject: ALS Emergency Services
Advanced Life Support Emergency Services?
birth-3 services
Subject: birth-3 services
he is talking about birht-3 special ed services. Is it supposed to be Birth-3?
Q--Dialysis Services
Subject: Q--Dialysis Services
You probably saw this in google already, but there is a Q--Dialysis Service in Alabama for veterans, if that fits? Otherwise, I would still think it is "acute".
S/L psychiatric CONVICTION services.
Subject: S/L psychiatric CONVICTION services.
The dictator is saying "He will continue with psychiatric s/l "conviction" services. That doesn't make sense to me - or am I missing something?? I can't find anything else that would fit either. HELP!! and THANKS!!
psychiatric counseling services? sm
Subject: psychiatric counseling services? sm
Individual, Group and Psychiatric Counseling Services
The Counseling Center is a short-term, focused treatment agency offering individual counseling, group counseling and psychiatric services.
www.bsu.edu/students/cpsc/services/ - 23k - Cached - Similar pages |
Psychological and psychiatric counseling services for Clergy ...
Psychological and psychiatric counseling services for Clergy, Priests and Religious professionals.
www.slbmi.com/psychology_religion/index.htm - 27k - Cached - Similar pages |
[10 years of social psychiatric counseling services in Hannover]
[10 years of social psychiatric counseling services in Hannover] [Article in German] Gephart W.MeSH Terms Community Psychiatry* Counseling* Germany, West ...
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=PubMed&list_uids=6218442&dopt=Abstract - Similar pages |
psychiatric outpatient services, maybe? nm
Subject: psychiatric outpatient services, maybe? nm
x
Most clients do not want services, departments,
Subject: Most clients do not want services, departments,
etc. capitalized unless stated as part of the hospital/clinic name,i.e.
XXXX Cardiology Service, XXXX Cardiology Department, etc.; therefore it should not be capitalized. In examples in BOS, thought not stated specifically, it would not be capitalized.
? psychiatric addiction services -- just a guess. (nm)
Subject: ? psychiatric addiction services -- just a guess. (nm)
x
I would say birth to 3 special education services
Subject: I would say birth to 3 special education services
Please help with pain management
Subject: Please help with pain management
mild L3-4 disc degeneration with annular s/l reversal
Thanks for any and all help here!
Pain management -
Subject: Pain management -
Patient has 5 Hertz resting tremor of the upper extremities.
How would you write that? Thanks.
Pain management s/l
Subject: Pain management s/l
Dorsal column stimulator s/l TAT 10 or PAT 10. I'm guessing this is a model but can't find anywhere.
A Baker Act is a means of providing individuals with emergency services and temporary detention...
Subject: A Baker Act is a means of providing individuals with emergency services and temporary detention...
Hollister-Steir laboratories provide allergy testing products and services.
Subject: Hollister-Steir laboratories provide allergy testing products and services.
So, Hollister would be correct.
It's pain management, the sentence is below, Thanks!
Subject: It's pain management, the sentence is below, Thanks!
she states, about 70% improved since going to our physical medicine and rehabilitation program with the trigger point injections, regenerative injection therapy, as well as Clasper laser therapy. I found the other word. Thanks again.
pain management specialist
Subject: pain management specialist
Under physical examiantion,
s/l * fay-ling's (sign) is negative, Tinel's is negative, Spurling's is negative. There is no Hoffmann's sign
Any help appreciated, thank you
There is a Byetta, management of diabetes...
Subject: There is a Byetta, management of diabetes...
Found in drug book.
I type for pain management
Subject: I type for pain management
and always type pain as 5/10. Nothing has ever been said, so I don't know if it's right or wrong.
Possible risk management issue
Subject: Possible risk management issue
I think the proper form would be to type it verbatim and then flag the report for possible risk management.
Pain management question -
Subject: Pain management question -
Discogram indicated pain at L4-L5 level which was concordant, but no pain at the L5-S1 level, which seems to be the worst level by MRI.
Injection of local anesthetic at the L5-S1 disc would help to s/l clarify the patient.
MRI ortho/pain management s/l please sm
Subject: MRI ortho/pain management s/l please sm
An MRI scan of the lumbar spine was performed in an open unit. The quality of the scan is poor.
There is a retrolisthesis on the scan at L5-S1 with a s/l shelf of disc material and possible impingement of the right L5 and S1 nerve roots with a left lateral disc osteophyte complex as well.
Has anyone ever heard the term shelf of disc material?
pain management or ortho help
Subject: pain management or ortho help
A post myelography CT showed s/l promenus disk and end plate degeneration at L4-L5.
pain management or ortho help
Subject: pain management or ortho help
Docs says patient had MRI scans done at s/l biv ska pig stone gap????
word help - pain management
Subject: word help - pain management
The patient will undergo diagnostic s/l putivly therapeutic costotransverse costovertebral joint blockade.
GAU evaluation
Subject: GAU evaluation
Does anyone know what this pertains to? I do not find anything in my Stedman's reference that would shed light on it. The patient is 51 years old and it is a very short dictation with little detail.
"medical management versus empiric gas CD" nm
Subject: "medical management versus empiric gas CD" nm
Pain management/ortho question - s/l
Subject: Pain management/ortho question - s/l
Patient continues to have foot and ankle s/l COPS or CRPS.
Glad to help. SM for some pain management refs. sm
Subject: Glad to help. SM for some pain management refs. sm
http://www.oregon.gov/DHS/pain/glossaryterms.shtml
==
http://jax.shands.org/hs/pain/services.asp
===
chronic pain management which s/l Zentene ???
Subject: chronic pain management which s/l Zentene ???
Patient was on ?? s/l Zentene management and informed she needed to taper off her OxyContin in order to decrease her narcotic demand postoperatively.
I found Services United for Mothers and Adolescents (SUMA) in a listing for adolescent drug rehab.
Subject: I found Services United for Mothers and Adolescents (SUMA) in a listing for adolescent drug rehab.
I don't know if this is what you are looking for, but it was listed in the Health Foundation of Greater Cincinnati.
evaluation and treatment?
Subject: evaluation and treatment?
x
Evaluation of right shoulder . . .
Subject: Evaluation of right shoulder . . .
Evaluation of his right shoulder shows he does have some atrophy in his 'p_____ disfaucet'.
I know that is not right, but that I was I get from his garble and what sounds like him eating the recorder. LOL
Thanks.
s/l fornik evaluation (sm)
Subject: s/l fornik evaluation (sm)
The patient had been on aspirin at the time of his stroke. He was changed to Plavix. He may be considered for __________ evaluation in the future.
This doctor flies through the dictation at warp speed, but the closest I can hear is "fornik."
Thanks.
Maybe "eval" for evaluation???
Subject: Maybe "eval" for evaluation???
x
Re-evaluation or Reevaluation?
Subject: Re-evaluation or Reevaluation?
Any idea whether this word has a hyphen or not?
Thank you
Could the doc just be stumbling on GU evaluation? Sorry not more help Nm
Subject: Could the doc just be stumbling on GU evaluation? Sorry not more help Nm
nm
maybe for "a VATS" evaluation ??
Subject: maybe for "a VATS" evaluation ??
s/l "Osfinder" evaluation of cervix
Preoperative diagnosis is:
RECURRENT HIGH-GRADE SQUAMOUS INTRAEPITHELIAL LESION FOLLOWING CONE BIOPSY AND CERVICAL STENOSIS PENDING PATHOLOGY.
Procedure is:
EXAMINATION UNDER ANESTHESIA, **OSFINDER** EVALUATION AND DILATATION OF THE CERVIX.
vVery muffled, but "--finder" seems clear (??).
sentence..Returned for re-evaluation of her...
Subject: sentence..Returned for re-evaluation of her...
blood pressure. She is on clathylone, verapamil 240 b.i.d., Mevacor 20 b.i.d., Prilosec, Flexeril, Mataglip and atenolol 25 a day.
She has had restriction of activity secondary to her let shoulder surgery and her right hip arthalgias.
Physical normal. She was given instructions to start water aerobics at the YMCA. A return visit in a year. Thats all the info I have.
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