Wiki 'reviewed family history' -PFSH question

[AmandaW]

Got ALL the documentation needed for a 99204 EXCEPT under the family history portion, it says 'Reviewed Family History'.

Is it appropriate to to send back an amendment request to add that in or is that "steering" the Dr into getting a higher level?


****OR****

Should I have no trail of the request and just verbally see if he wants to amend the note?

 

[Chelle-Lynn]

It is recommended in these types of situations that your office have a policy on when records should be re-routed for amendments. This will avoid the appearance of directing the provider to document for a higher level of service.

In this case, it may just be a training issue with the provider in regards to what is needed to be documented to allow for a review of family history. I would approach the provider as a training opportunity using the record you have as an example. If after the training the provider feels that he can provide additional clarification to the records then he would have the option to amend the records.

The issue of whether to approach the provider verbally or in writing should be moot...as whether or not the action is documented we should always be ethical in how we handle these situations. If you feel that a trail would be problematic then it would make me question whether the action you are taking is in act an appropriate and ethical option.

 

[thomas7331]

I agree, this is a question to put to your supervisor or manager and you should have a process in place - provider time is valuable and there should be a framework for when and how to get feedback to providers based on the office's priorities. Personally, I would not query a physician or otherwise take up their time for something like this as I would consider it a technicality and, put in perspective, this is not something that poses a high audit risk or significant financial liability - if it is something isolated, I would let it go but make a note of it for discussion with the provider at an appropriate time. In most practices I've worked for, the goal is to have good documentation, not perfect documentation, and in my experience, if you start asking providers to amend individual notes for details like this it can quickly become a major irritation for them.

 

[AmandaW]

Thank you guys for your responses. I understand this looks minor but there is NO credit given for this family history, correct? And on a new patient it's a difference of having to knock it down a whole level - from a 99204 to a 99203 with needing 3 out of 3 PFSH.
Or I completely wrong and auditor would just glaze right over it and not penalize us?

My Drs are currently receiving 'refresher' education on this as they've been told for years now. With new scribes coming and going, MA's, nurses, ancillary staff- documentation details tend to get skipped, resulting in what could be a big financial loss if not gotten under control.

 

[thomas7331]

It is difficult to say what an auditor would do, just as it is difficult to say what a coder would do, because roles and guidelines vary by organization, as do their relationships with payers and tolerances for risk. A strict auditor would cite it as an error and take back the overpayment, but in my experience, payers audit E&M codes to look for trends of abuse and chronic up-coding that add up to a lot of money, not to find $30 here and there by challenging minor details in how the provider worded their documentation. I really doubt that a auditor would find fault with this as they're usually looking mainly to see if the level is supported by the patient's problems and they don't want to generate appeals, but you never know.

But again, I'd refer you back to your organization and what your role is. If your job is to choose the code or to correct the provider's code, then you should follow your guidelines and pick the appropriate code based on your training. If your job is to validate what the provider has chosen, then your practice should be the one to tell you what steps you need to take when you identify a variance between your code and the provider's. But in either case, in that situation myself, I would not submit a query or request an addendum for something of this magnitude - the amount of time it will take you and the provider will likely exceed the value of the difference in reimbursement between the levels.

 

[twizzle]

Reviewed family history

Got ALL the documentation needed for a 99204 EXCEPT under the family history portion, it says 'Reviewed Family History'.

Is it appropriate to to send back an amendment request to add that in or is that "steering" the Dr into getting a higher level?


****OR****

Should I have no trail of the request and just verbally see if he wants to amend the note?

From an auditor's perspective (at least from my perspective as an auditor in this situation) I would give no credit for the statement 'reviewed FH' because it provides no information. FH ideally should be relevant to the patient's problem but in any case, what did the review reveal? Something or nothing?

For a cardiology patient for example, if they reviewed the FH and there was a strong FH of sudden cardiac death, wouldn't you want to know that? Wouldn't other providers seeing the patient down the line want to know that?

Providers create documentation for many reasons, one being to create a 'paper trail'. There could be legal consequences for failing to document positives and negatives but if it's documented there is no argument....and yes, you would be steering your provider. By all means educate them for the future but don't encourage them to add information after the fact.