SHIBA425
Guest
Has anyone audited a Prenatal Flow record for the documentation of prenatal E/M visits? Or an ACOG approved prenatal Record?
If so, when a patient presents for a routine prenatal follow-up visit with no problems, or concerns (just a plain prenatal visit) are you getting a 99212 or 99213. Now I realize it depends on what the provider documentes, lets say they only document :
FHR, fundal height, wks gestation, fetal movement, weight this visit, BP, edema, pain/pressure, and states no complaints. I would say a 99212.
Problems I have with this documentation are there is no Medical Decision Making documented. I am aware that you would only need 2 of 3 key components, but shouldn't there be something listed for MDM for some of these "routine" prenatal follow-ups? Also, the final diagnosis is not specifically stated in this note. I am not aware of any guideline that states you can infer or assume a diagnosis if it is not documented.
Please feel free to give any and all responses, I am looking for all kinds of input.
Thanks Jeanne F.
If so, when a patient presents for a routine prenatal follow-up visit with no problems, or concerns (just a plain prenatal visit) are you getting a 99212 or 99213. Now I realize it depends on what the provider documentes, lets say they only document :
FHR, fundal height, wks gestation, fetal movement, weight this visit, BP, edema, pain/pressure, and states no complaints. I would say a 99212.
Problems I have with this documentation are there is no Medical Decision Making documented. I am aware that you would only need 2 of 3 key components, but shouldn't there be something listed for MDM for some of these "routine" prenatal follow-ups? Also, the final diagnosis is not specifically stated in this note. I am not aware of any guideline that states you can infer or assume a diagnosis if it is not documented.
Please feel free to give any and all responses, I am looking for all kinds of input.
Thanks Jeanne F.