General Coding Documentation Tips – Do’s and Don’ts
Source: The Physician Compliance and Monitoring Manual
There are many approaches to documentation of rvices that will go a long way towards ensuring compliance. Much of this is common n while some may not be as obvious. Find below some basic tips.他一定是疯了用英语怎么说
Do U Templates to Assist in Documentation
The history and exam portions of the encounter are often the source of missing elements or areas associated with the code chon. While the code may be correct relative to the overall level of decision making, it may be missing some aspect of history or exam required to support the code from a documentation perspective.
Templates are a uful way to record ‘normal’ exam findings, to update Past, Family and Social History, or to rve as a prompt to providers for the elements of an encounter that need to be documented. Printed templates are the precursor to the electronic medical record – get ud to the idea.
Don’t Misu Templates
Templates can be easily abud by practices such as checking off all exam items or drawing lines through entire ranges or organ systems. The history ctions can be summarily addresd and neglect to include the date that, for example, the past history was updated from. Templates are uful to assist in documentation, not replace it. The documentation needs to be in proportion to the reason for the visit – a level five or comprehensive exam for a an acute single-system illness or problem strains credibility – where is the medical necessity in this. Templates can drive this type of misu.
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Do Be Certain the Provider Address the HPI
Recent clarification by CMS indicates that the History of Prent Illness must be addresd in some fashion by the provider. Although ancillary staff, nurs, and nur medical assistants record ROS and PFSH, the provider must either perform or indicate specific knowledge of the HPI. If an entire HPI is not repeated when taken by other staff, at the very least the provider should indicate “HPI as above significant for xxxx.” This is borrowed from the teaching guidelines but should suffice to meet the standards.omie
Do Remember that New Patient and Consult Codes Require All Three Components of E/M
Becau the established patient codes often compri the bulk of a physician’s rvices, providers can get into the habit of documenting either history or exam at a certain level. Frequently an exam will be fairly complete, but only address six of ven organ systems. The higher levels, four and five, of new patient and consult codes require a comprehensive exam, and a comprehensive history. The very nature of a new patient of consult type encounter will necessitate the taking of greater history – but be certain it is complete enough.
Don’t treat new and established patient documentation the same.
Don’t allow ancillary histories to stand alone without provider commentary and additions.
Do Make a Rule for Your Providers That for Established Patients, of the Two Required Components of E/M – Medical Decision Making Is One of Them
The rule that requires only two of three E/M components for an established patient visit can be dangerous. The safest way to view this is that either the history or exam will act as the supporting performance and documentation element of the correct level of rvice bad on medical decision-making. Make sure decision-making is one of the two – it will keep the encounter rooted in medical necessity. Technically, if a comprehensive history and physical was performed with a low-level pre
slack off
nting problem, the encounter could be coded as a level five. This would not however meet medical necessity standards. The documentation should always be in proportion to the rvice required.
dkny怎么读>fprintfDon’t rely on beefy histories and exams alone to support high-level rvices.技术资料翻译
Do Make Certain Decision Making Is Clearly Documented
The key to code lection and ironclad documentation of the critical element of E/M is here. In most cas when decision-making at a certain level occurs, the degree of history and exam will follow. Most efforts to teach physicians the documentation rules put the cart before the hor so to speak, and attempt to teach all the different elements of history and exam before decision-making.
Physicians should be encouraged to identify the level of rvice in the first few moments of the encounter. The table of risk and decision-making matrices in all versions of the Federal Documentation Guidelines give a range of acuity from uncomplicated through critical episodic prentations. They also list a quantitative progression of chronic conditions. In most cas, the physician will know early in the encounter what types of problems are being prented, or how many problems are to be addresd. Even when confronted with an unknown new problem, this is clearly earmarked as at least moderate level decision making. Of cour, some encounters may take a dra
matic turn after the initial prentation, but most do not. Often not documented are the differential diagnos, rule-outs, and potential morbidity/mortality problems. List the under
‘impression’ or ‘cour’.
Document for each problem encountered, the problem or condition, the status of the , well-controlled, worning etc, and the management options. Give the regulator what they are looking for. In the asssment and portion of the chart simply state “HTN” well controlled continue Toprol,” or “COPD exacerbation consider O2 Tx.”
Don’t simply state “continue prent meds” or “follow-up in 3 months.”
Do Address Teaching Physician Guidelines
A safe harbor approach is to have the attending physician weigh in on each aspect of the encounter, ‘History as above significant for….., on my exam…..and management includes…..’ Leave no doubt as to attending physician’s involvement.
Don’t rely on the old “en and agree.”
Clarify Oversight When 99211 is Coded
Do be certain that providers sign off and are involved in 99211 rvice.
Don’t assign 99211 codes to rvices the provider did not participate in, and sign off on.
Do be certain that ‘incident-to’ rvices are appropriately overen and counter-signed.
Don’t u a physician provider number when they are not prent or available (payer-specific). Document Appropriately When Modifier – 25 Is Ud
Since the definition of modifier – 25 is “parate, significant and identifiable rvice provided on the same day as a procedure or other rvice”, make sure the documentation address each of the. When two rvices are provided, e.g., “visit and procedure,” or, as above, “medical visit and health maintenance, “break the chart into two ctions. Label the ctions “procedure,” and “maintenance and medical management.” Leave no doubt for anyone who checks what was done. If you have two rvices, document two rvices. Learn when only one can be charged. Don’t add an E/M visit to every office procedure performed (this is quite common).
sugar是什么意思NOTE – For all provider types: Remember that hospital admissions require comprehensive histories and exams at the two higher levels of admits. Much Federal auditing is done for the rvices, pre
x boxcily becau this is where documentation deficiencies often occur. All admits levels Two and Three require a complete (10) ROS! This area probably yields more deficiencies than any other. Hospitals generally require a complete “H&P”; don’t forget this history element. Under current guidelines this can be met by indicating “all other ROS negative” after reviewing problem – pertinent systems, assuming the other systems were reviewed.
The same goes for subquent hospital visits. Here the exam is often not very substantial (the patient just having a had a ‘complete’ H&P on admission), but do not overlook it. It is almost always best to u the general system-level approach here. Key history tips here are to mention the interval history, i.e. “taking po better, afebrile, responding well to xxxx”. Many subquent hospital notes are scanty to say the least. This is a prime risk area.
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