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JustCoding News: Outpatient, December 2, 2009

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I am coding a new admission to our nursing home. The physician wrote a very short history and physical: “Suffered aneurysm, 12/08 had clipping, VP shunt, significant deficits noted.” How can I ask the physician to elaborate on the deficits? The nursing notes from the hospital stay state right-sided weakness and mental and speech impairments. I’m worried about how to word the query because I know you aren't supposed to pose leading statements. Can anyone provide me with some examples of an appropriate query?
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