Medical nec./compliance

[Sarah Ann]

We are being told by management it is OK to use orders, results and prior office visits for a covering diagnosis for med. necessity.
As far as I know we can only use the date of service and provider documenation. Which is correct?

 

[sls314]

We are being told by management it is OK to use orders, results and prior office visits for a covering diagnosis for med. necessity.
As far as I know we can only use the date of service and provider documention. Which is correct?

The documentation for each date of service should stand alone. You are correct.

 

[jkyles]

I would just add that in addition to creating improper claims, doing so could also create patient safety issues.

 

[thomas7331]

We are being told by management it is OK to use orders, results and prior office visits for a covering diagnosis for med. necessity.
As far as I know we can only use the date of service and provider documention. Which is correct?

There isn't a yes or no answer to this question - it's going to depend on what services you're coding for, and what information you're pulling from those records.

As a general rule, if you're coding for physician services, it's true in most cases that you can only use documentation from the current encounter. You can't assume that information from prior encounters is still current unless the physician has confirmed this in the record. But if you're coding for ancillary services that were ordered by a physician at a prior encounter or earlier date of service, then it may be appropriate to look at older records. Orders are not always written on the same date that those services are actually executed. Organizations may have internal policies as to how long an order remains valid. So if you're coding for things like diagnostic tests - e.g. labs, x-rays - or therapeutic services - e.g. infusions, PT, OT - that a physician has ordered prior to the current date, then it may be appropriate to review the ordering physician's notes from encounters from which those orders originated in order to get additional information from which to assign codes.

You should question your management about this and discuss it with them if you don't understand their rationale or are uncomfortable with their guidance. There may be valid reasons they're asking you to do this.

 

[Sarah Ann]

Yes, I should have clarified, it's for the professional E/M encounter. It makes sense to look at orders for anc. services.

 

[thomas7331]

Yes, I should have clarified, it's for the professional E/M encounter. It makes sense to look at orders for anc. services.

Then yes, I'd agree you should only assign codes for that encounter. But then why are they asking you to do this for medical necessity reasons? There aren't any medical necessity limitations or LCDs that apply to E/M codes.

 

[Sarah Ann]

No but sometimes You'll find non- covered tests for office visits.