https://learning.nationalspinemanagement.com/wp-content/uploads/2021/02/National-Spine-Management-Group.jpg-ICON.jpg 0 0 admin https://learning.nationalspinemanagement.com/wp-content/uploads/2021/02/National-Spine-Management-Group.jpg-ICON.jpg admin2015-03-27 15:04:172015-03-27 15:04:17Diagnosis and Reporting
Some of these questions are simple, but we dont often think about them until we need the information! See below.
Question on the initials, do I diagnose a ACDF [Anterior Discectomy and Fusion] or just place it under surgical history?
You would place it under surgical history with a hyphen and then the year, so you would do the following in your note. We dont want to abbreviate either, so you would write it out. Rember surgical history is one of MANY requirements for CPT coding inital E/M codes. If you need a better format, please see the Sample Report in the Communication Section.
Cervical Fusion – 2015
Do I mention in my initial that the patient has already seen the neurosurgeon and the physiatrist?
Yes, but keep it simple. Remember that the primary care MD is going to use your report to get INSTANTLY caught up on the patient’s care. So as far as the history of who they have seen, you can put one line in there that says…
The patient has been evaluated by the neurosurgeon as well as their physiatrist for evaluation and continued care. They present today for examination and treatment of their biomechanical spine condition.