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E/M Coding Education: Does ‘No SOB’ Fall Under HPI or ROS?

Question: For a chart with a chief complaint of resolving pneumonia, a note indicates, “No coughing, SOB.” Should I give the pediatrician credit for this ‘no coughing & no shortness of breath’ statement under history of present illness (HPI) or as a review of systems (ROS)?
Answer: This is a gray area of E/M coding that […]

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Fracture Care Coding: Mark Manipulation, Make $100+ More Per Encounter

No maybes here: Answer this question wrong and you will code incorrectly.
When your ED physician performs fracture care for a patient, be ready to pounce on evidence of manipulation, as CPT often breaks fracture care codes along the manipulation line.
The $kinny: Let’s say the physician performs closed treatment on a fractured collarbone; if she uses […]

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