RE: [CRN-L] Documentation Guidelines/long question
- Slight correction. No ROS for any of the established patient codes
doesn't make much difference as you only need 2 of 3.
Question 1: I agree with Jo Ann. The only thing the comment supports is
it can be used in the MDM. Question 2, Again I agree, mostly. For
Medicare, the 2 visits can not be on the same day [MCM 15501]. For
payment purposes and audit, it should be very clear that there is
something [knowledge of malaria TX] that the 2nd MD brings to the
treatment. Question 3, I'm a little more intense in my answer. No ROS,
even by reference, = 99201, 99212. The Guideline specifically state that
to include a ROS that is found elsewhere there must be a reference to it
and any changes.
Quinten A. Buechner, M.S., M.Div., C.P.C., C.H.C.O.
President, ProActive Consultants, llc
1659 3rd Avenue
Cumberland, WI 54829
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From: Jo Ann Steigerwald [mailto:jsteiger@...]
Sent: Friday, July 30, 2004 11:47 PM
Subject: Re: [CRN-L] Documentation Guidelines/long question
1st question: The record should show the order for any diagnostic tests
including x-rays, and if they were taken there, there should be a report
the findings. Because of the limited information on this one, is there
chance the patient brought the films in from another site?
The section in the MCM that deals with consults does address consults in
the same practice, and does not state that one cannot ask a
for a consult. As always, medical necessity is the key, so if the
physician has additional training or experience in a given condition, or
some cases, because the patient doesn't seem to respond to the 'usual"
therapies, a doctor will request an evaluation from a
same-specialist. Basically, if they meet the carrier's manual
for a consult, its a "consult".
3. I advise all physicians to reference any material in the chart that
needed to consider their treatment for that particular date...whether
"need" it for coding or not. Its not only good medical practice, its
good risk management. If its present, and they "use" it, they should
that in their chart entry.
Jo Ann S
At 11:12 PM 7/30/2004, you wrote:
>I have a couple of questions I want to ask.clinic?
>First, I'm reviewing charts at a family practice clinic. The chart
>note indicates that the physician did not see anything in the lumbar
>x-ray. So I started wondering, did he do the x-ray there at the
>They have the equipment, they do them, but I couldn't find anythingon the
>that said they did it there. There is no physician order for the x-ray,
>there is no radiology report in the
>chart, the only note about this was that one statement "nothing noted
>lumbar x-ray". What exactly are the documentation requirements when aneeds
>orders x rays or certain labs that are done in their office? What
>in the chart?
>My second question has to deal with consultations...everyone's favorite
>subject. I have a family practice M.D. who wants to refer a patient to
>another physician in his practice who also is a family practice doctor
>for his opinion.
>They operate under the same tax id# and they both have the same
>I know a physician in a group practice can refer a patient to aspecialist in
>the same group practice, and as long as there is a request for ain the
>the consultation noted in the chart and a letter or some sort of note
>chart back to the requesting doctor, this qualifies as a consultation.physician
>However, when one physician is requesting the opinion of another
>same specialty, does this qualify as a consult? My gut instinct is no
>not, but I need to provide the documentation to back up that decision.
>Third question, in reviewing these charts, I notice under the regular
>visits, there is never a mention of the ROS. They use a health history
>questionnaire that the patient fills out on their new visit and if they
>have an annual exam. There is never a note about it, they do not refer
>to it in their documentation. Nothing like "ROS from date....reviewed
>no changes" or if there are changes notes regarding that. So as I am
>reviewing these charts, there is no ROS
>on any of them and therefore I cannot get a history level higher than a
>problem focused history. I know for the established patient, you only
>need 2 out of
>the 3 levels, and I suppose for a new patient you would have a ROS, so
>it doesn't matter. Has anyone else ran up against this and how do youadvice
>a physician regarding this type of documentation? Thanks[Non-text portions of this message have been removed]
>Chris Felthauser, CPC
>PMCC Approved Instructor
>[Non-text portions of this message have been removed]
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