Tammy Posted Mon 31st of August, 2015 09:30:50 AM
provider comments on the master report states:
all s/e of immunization including fever, rash, irritability, lethargy d/w parent. Tylenol and Motrin alternate prn. call if question.
I have read where "counseling" components needs to be on the master.
I am not sure if what he has written under his comments is enough and warrants the counseling code even though he never states the wording counseling but it is what he is doing? please let me know your thoughts.
SuperCoder Answered Tue 01st of September, 2015 01:29:50 AM
The provider should provide vaccine counseling, in terms of questions related to vaccine administration and adverse reaction, complication, etc. It is not mandatory to write counseling word in the record. The documentation provided above in query indicate that provider has provided relevant vaccine counseling to the patient and parents.