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AAPC member Meenu Agarwal, CPC, CRC, CEMC, CPCD, CPEDC, has five and a half years of work experience in medical coding and auditing and currently works as a medical coder in Portland, Oregon. AAPC asked Agarwal about her experience with earning the Certified Evaluation and Management Coder (CEMC™) credential and how it has helped her […]
The post Advice From a CEMC™ appeared first on AAPC Knowledge Center.
I became an AAPC member because of my mom. She was a certified coder with a specialty certification in obstetrics/gynecology and worked in medical offices while I was growing up. I remember my sister and I watching her study for her certification. My dad, a registered nurse and auditor, is also a member of AAPC. […]
The post I Am AAPC: Sara Harvey, CPC, CEMC appeared first on AAPC Knowledge Center.
I am studying for the CEMC and am scheduled to test 02/24 (eeeekk – close!)
As I am working my way through the study module and practice guide and I seeing the importance of a really good audit tool. Currently I am using two – half of one and half of another. I like Trailblazers for the HPI and exam; however I like the AAPC Audit Form for the MDM.
Does anyone have any suggestions or recommendations of an audit tool that they found helpful?
I would like to settle on an audit tool by the time I take the practice exam to give myself time for comfort and consistency in use of the tool.
My other option is to ask AAPC is I can use my own audit tool in the exam by combining the parts of the two documents I like into one.
Last question; how many audit tools did you bring into the exam with you. Would you estimate 25 would be a sufficient number?
Thank you for any suggestions!
Case 1-EM 2
The physical exam portion documents clear findings under the following headings (I’ve listed the organ system I associated to each in parenthesis):
Head and Neck-(Musculoskeletal)
Thyroid (Lymphatic)
Lungs (Respiratory)
Heart (Cardiovascular)
Abdomen (GI)
Breasts, Pelvic, Vulva, Cervix, Vagina, Uterus, Adnexa-(GU)
However, this is where I think I may be confused…
The BP is documented (Constitutional)
Then it shows General-WNL, no apparent acute distress
Does "no apparent acute distress" not account for the Psychiatric? The rationale states the exam, according to 1995 guidelines, is detailed due to detailed findings in 2-7 body areas/organ systems. I’m guessing I am misinterpreting the distress as part of the Psychiatric instead of General Appearance under Constitutional. However, I don’t understand why this wouldn’t count as "Mood and Affect" which includes descriptors such as anxiety and agitation.
Case 2-EM 5
The physical exam portion documents clear findings under the following headings (I’ve listed the organ system I associated to each in parenthesis):
Integument (Skin)
Ears, Nose/Sinus, Throat/Mouth (ENMT)
Lungs (Respiratory)
Heart (Cardiovascular)
Abdomen (GI)
Head (Musculoskeletal)
General-A&O x3, no acute distress (Psychiatric)
This is where I think I’m missing something:
The HT, WT, and Temp are documented in the note, but underneath the HPI and not in the actual PE part of the note. Can those vitals still be counted as part of the Constitutional? The note doesn’t specifically state one way or another whether or not the actual physician took the vitals or if it was the tech/MA…
With that being said, it is also documented under Neck, "Supple without Lymphadenopathy". Therefore, can you not count the "without Lymphadenopathy" as part of the Lymphatic system instead of grouping the neck with the Musculoskeletal? The 1995 guidelines (which were used in the rationale) only state that for the comprehensive general multi-system examination, it only has to include "findings about 8 or more of the 12 organ systems".
The note clearly documents findings in 7 systems. Therefore, the Constitutional or the Lymphatic would make 8 (or 9), but the rationale for the note is that it is a Detailed exam based on 1995 guidelines due to detailed findings in 2-7 body areas and/or organ systems.
Can someone explain where I am wrong (or maybe right??) in my justification? This is driving me crazy!!
Dawn Wachtel, CPC, CPB
Currently I am preparing for my CEMC exam and need some clarification in the question pattern. I aware of that the exam should be the case study.
I would like to know that they are examine only the level of coding and ICD and anatomy/physiology/medical terminology or else I have prepare other than that.
If yes means please let me know what are the topics which I have to covered it and I have saw that they are testing the teaching physician guideline and incident to / share / split service guideline which was mentioned in the AAPC website.
Please guide me on that how many question will come in each topic if possible. Please help me and share if you have any model question/related notes to [email protected]
Please guide me and your support was highly appreciated
Thanks in advance.