One common problem with provider documentation is a missing chief complaint (CC). Unless the visit is for a preventive medicine service, the lack of a CC means that the service will be deemed medically unnecessary (and unpayable) by any insurer. Often, providers begin their subsequent notes with symptoms the patient may not have, or a comment ...
In Coding
Jun 26th, 2013
When documenting elements of an evaluation and management (E/M) service, a notation of “Family History Reviewed,” for instance, is insufficient to satisfy the element. Guidelines require more than a simple note of “reviewed” to fulfill the documentation requirement. Both the 1995 and 1997 documentation guidelines specify, “A ROS and/or a PFSH obtained during an earlier ...
Jul 1st, 2011
Know the specifics so you’ll be current with home health service requirements. By Christopher A. Parrella, JD, CHC, CPC, CPCO Effective April 1, the Centers for Medicare & Medicaid Services (CMS) implemented new face-to-face encounter requirements for home health services (MBPM30.5.1.1). This new rule requires the certifying physician document all face-to-face encounters conducted with patients...