Patient history is valuable any time you're building up your documentation to show medical necessity for reimbursement of any procedure. Any time you are coding for problem visits that a patient has, it is important that you take into consideration any other office visits that they may have recently had. Basically, you are going to want to look to see if there is a connection between visits for preventative medicine as well as current health issues that may be in place, which also needs some attention.

Many times, a physician will end up seeing a patient that shows up in search of a visit to fall into the category of preventative medicine. Then, upon further evaluation, the doctor will then need to look at the patient further for some sort of significant problem that they have. As a coder, you may end up finding yourself in a situation where you are not sure if you are to code the visit under a new or established patient.

This type of a situation will call for a fast judgment call on your part. In order to make sure that the practice receives reimbursement and avoids denial, you can always go with a new patient code to begin with. Then, after you look through and take all of the medical documentation into account, you can see if there is a modifier that you can add on. A good rule of thumb is to always take the procedure, documentation and time lapse between visits into account before you record the code.

Labels: claims, medical-coding, medical-data, outsourcing, paper-trail