sankoe@keystoneruralhealth.com
Networker
Looking for some clarification. I have a behavioral health provider that I'm currently auditing her charts. I'm finding that she is sending dx over to billing that I feel are not assessed in turn I am flagging them. This provider has questioned me regarding these flags.
Provider: I am just looking for some clarification as to why I am receiving so many messages from you pertaining to my documentation. Has there been some type of process change that I am not aware of because in the 2 years I have been here I have probably had less than 5 billing questions sent to me. My notes are all billed using time based coding. Any insight would be appreciated.
My response: I've noticed several diagnoses in your Assessment that lack supporting evidence in your notes. Please review these findings and feel free to leave them as is, as they are simply suggestions to improve documentation alignment. While your documentation remains at your discretion and I am not adjusting levels based on time, I want to ensure it meets the medical necessity required to bill for those specific diagnoses.
Provider: I appreciate you getting back to me. I was just trying to make sure there had not been a process change or something. I will say as far as your recommendations are concerned that my particular style has never been to address every single diagnosis that is listed in the assessment and plan in my HPI if there are no specific concerns brought up or discussed pertaining to that diagnosis. When I write that a “patient denies any other complaints or concerns at this time” that is my equivalent to saying that psych ROS is otherwise negative. These are all chronic conditions that are still present even if there are no active symptoms which is why it can still be listed on billing. For example if they have PTSD but are not experiencing any nightmares or flashbacks during the interval I just lump that under a general denial of any other symptoms.
I do not feel that lumping dx (under a single phrase as mentioned above) that were not specifically addressed is good practice. I feel I should drop these from the claim if she does not wish to add to her documentation. The note below is one of several in question please give me your insight on whether the note is sufficient to bill for PTSD.
Also the provider a PA-C is being billed under Physical Health as the insurance companies do not recognize her behavioral health certification and they are only doing med management.
Example:
Identifying Data: Patient is a 43-year-old male currently being seen for the management of depression, anxiety, PTSD, ADHD, and alcohol use disorder.
Chief Complaint: Stopped Prozac, believed this was raising his BP and was making him extremely thirsty
Also having new onset memory issues
Subjective (Interval History): Patient presents today for follow-up accompanied by his wife. It has been about a month since his previous visit with the writer. At that time he was to increase Prozac to 40 mg daily. Patient states he did stop taking the Prozac about 5 days ago due to concerns that he may have been having side effects from it. He states shortly after increasing the dose from 20 mg to 40 mg he started experiencing excessive thirst and more frequent urination. He also had his yearly employment physical which he did not pass due to high blood pressure. He states he has never had problems with blood pressure in the past. His wife has checked his pressure several times at home since and it has remained elevated. It has still been elevated today despite having not taken the Prozac in 5 days. He denies any recent headaches or visual disturbances. He denies any chest pain or shortness of breath. His wife also reports that he has had new onset "memory issues" recently. She states he has been more forgetful and several times she has had conversations with him about something that he then is not able to recall at all when he gets brought up again within a day or two from the original conversation. Patient has still been drinking alcohol daily. He averages between 6-8 beers a day. He has not gone any days without drinking. Patient and his wife acknowledge a very strong family history of diabetes. His wife states he has been checked multiple times for diabetes but has never had an elevated blood sugar or A1c. He was given a fingerstick glucose test today during the appointment which came back normal at 97. Patient states he has been generally sleeping okay aside from having to get up and urinate. His appetite has been good. He has been eating consistently. He does acknowledge that his mood has been a little bit more irritable since stopping the Prozac but he has not had any major anger outburst or significant agitation. He presently minimizes
any significant depressive symptoms. He does report some occasional anxiety primarily related to work but nothing that has been overly severe persistent. He denies any current issues in regards to attention and focus. He denies any suicidal thoughts or feelings of hopelessness. He denies any other complaints or concerns. Patient was agreeable to remaining off of Prozac at this time although the writer does not suspect that is the cause of his hypertension or other recent physical symptoms. He will contact his primary care provider for further evaluation.
Mental Status: Patient is alert and oriented x 3. Grooming and hygiene are adequate. Eye contact is good. Speech is normal in rate and amount. Psychomotor activity is within normal limits. No tics or tremors are noted. Patient ambulated unassisted with a steady gait. Mood is described as "okay I guess." Affect is broad. Thoughts are logical and goal directed. Thought content contained no evidence of delusions. Patient denied any visual or auditory hallucinations. Patient denied suicidal or homicidal ideation. Judgment and insight are limited.
Assessment: MDD, recurrent, moderate–chronic
Anxiety Disorder, unspecified - chronic
PTSD - chronic
ADHD, unspecified - chronic
Alcohol use disorder - chronic
Depression Screening
Plan: Patient will remain off of psychotropic medication at this time. He was encouraged to follow-up with his primary care provider regarding new onset hypertension accompanied by polydipsia and polyuria. Patient was advised to go to the emergency department should he experience any difficulty with severe headaches, chest pain, shortness of breath, or altered mental status. He will follow-up with the writer in 1 month. Patient was instructed to call with any concerns or problems.
Provider: I am just looking for some clarification as to why I am receiving so many messages from you pertaining to my documentation. Has there been some type of process change that I am not aware of because in the 2 years I have been here I have probably had less than 5 billing questions sent to me. My notes are all billed using time based coding. Any insight would be appreciated.
My response: I've noticed several diagnoses in your Assessment that lack supporting evidence in your notes. Please review these findings and feel free to leave them as is, as they are simply suggestions to improve documentation alignment. While your documentation remains at your discretion and I am not adjusting levels based on time, I want to ensure it meets the medical necessity required to bill for those specific diagnoses.
Provider: I appreciate you getting back to me. I was just trying to make sure there had not been a process change or something. I will say as far as your recommendations are concerned that my particular style has never been to address every single diagnosis that is listed in the assessment and plan in my HPI if there are no specific concerns brought up or discussed pertaining to that diagnosis. When I write that a “patient denies any other complaints or concerns at this time” that is my equivalent to saying that psych ROS is otherwise negative. These are all chronic conditions that are still present even if there are no active symptoms which is why it can still be listed on billing. For example if they have PTSD but are not experiencing any nightmares or flashbacks during the interval I just lump that under a general denial of any other symptoms.
I do not feel that lumping dx (under a single phrase as mentioned above) that were not specifically addressed is good practice. I feel I should drop these from the claim if she does not wish to add to her documentation. The note below is one of several in question please give me your insight on whether the note is sufficient to bill for PTSD.
Also the provider a PA-C is being billed under Physical Health as the insurance companies do not recognize her behavioral health certification and they are only doing med management.
Example:
Identifying Data: Patient is a 43-year-old male currently being seen for the management of depression, anxiety, PTSD, ADHD, and alcohol use disorder.
Chief Complaint: Stopped Prozac, believed this was raising his BP and was making him extremely thirsty
Also having new onset memory issues
Subjective (Interval History): Patient presents today for follow-up accompanied by his wife. It has been about a month since his previous visit with the writer. At that time he was to increase Prozac to 40 mg daily. Patient states he did stop taking the Prozac about 5 days ago due to concerns that he may have been having side effects from it. He states shortly after increasing the dose from 20 mg to 40 mg he started experiencing excessive thirst and more frequent urination. He also had his yearly employment physical which he did not pass due to high blood pressure. He states he has never had problems with blood pressure in the past. His wife has checked his pressure several times at home since and it has remained elevated. It has still been elevated today despite having not taken the Prozac in 5 days. He denies any recent headaches or visual disturbances. He denies any chest pain or shortness of breath. His wife also reports that he has had new onset "memory issues" recently. She states he has been more forgetful and several times she has had conversations with him about something that he then is not able to recall at all when he gets brought up again within a day or two from the original conversation. Patient has still been drinking alcohol daily. He averages between 6-8 beers a day. He has not gone any days without drinking. Patient and his wife acknowledge a very strong family history of diabetes. His wife states he has been checked multiple times for diabetes but has never had an elevated blood sugar or A1c. He was given a fingerstick glucose test today during the appointment which came back normal at 97. Patient states he has been generally sleeping okay aside from having to get up and urinate. His appetite has been good. He has been eating consistently. He does acknowledge that his mood has been a little bit more irritable since stopping the Prozac but he has not had any major anger outburst or significant agitation. He presently minimizes
any significant depressive symptoms. He does report some occasional anxiety primarily related to work but nothing that has been overly severe persistent. He denies any current issues in regards to attention and focus. He denies any suicidal thoughts or feelings of hopelessness. He denies any other complaints or concerns. Patient was agreeable to remaining off of Prozac at this time although the writer does not suspect that is the cause of his hypertension or other recent physical symptoms. He will contact his primary care provider for further evaluation.
Mental Status: Patient is alert and oriented x 3. Grooming and hygiene are adequate. Eye contact is good. Speech is normal in rate and amount. Psychomotor activity is within normal limits. No tics or tremors are noted. Patient ambulated unassisted with a steady gait. Mood is described as "okay I guess." Affect is broad. Thoughts are logical and goal directed. Thought content contained no evidence of delusions. Patient denied any visual or auditory hallucinations. Patient denied suicidal or homicidal ideation. Judgment and insight are limited.
Assessment: MDD, recurrent, moderate–chronic
Anxiety Disorder, unspecified - chronic
PTSD - chronic
ADHD, unspecified - chronic
Alcohol use disorder - chronic
Depression Screening
Plan: Patient will remain off of psychotropic medication at this time. He was encouraged to follow-up with his primary care provider regarding new onset hypertension accompanied by polydipsia and polyuria. Patient was advised to go to the emergency department should he experience any difficulty with severe headaches, chest pain, shortness of breath, or altered mental status. He will follow-up with the writer in 1 month. Patient was instructed to call with any concerns or problems.