Wiki Compliance

[REGINALD068]

Happy Holidays Fellow Coders

I audit claims for a multi-specialty Practice, and review over 100 files per day. To make the process less suicidal, and to move quicker, I have requested all Providers to please follow and use the same template for the required elements for ROS, PFSH, and Exam Components(Body Areas/Organ Systems) and to use the "Headings" listed in the CPT manual. I have one Provider who absolutely refuses to do so. Not only are his notes a copy and paste from the IE to all f/u's(big no no), but I have to the match game to see if he's hitting all of the required elements for the level of service he's billing. I spoke to the Administrator about it, but he feels if it's not a compliance issue, let he do as he pleases.

Is there anyone who knows if listing the elements under headings other than what's listed in the CPT manual is viewed as non-compliant, please let me know where I can find that information.

Examples of how this Provider is choosing to list his own elements: for PFSH - instead of listing it like this:
Past- Knee Sx, Joint pain, allergic to pollen ragweed.

He lists it like this thinking he has satisfied the elements for 99204 which requires all 3 elements of PFSH, when in reality, he's only provided information for PAST History.

Allergies - Pollen, ragweed

Medical - Knee joint pain

Surgeries - Knee

For Body Areas/Organ Systems he does this:
HEENT - unremarkable (this is actually three separate elements. Can all three be listed together with one finding?)
Heart -instead of Cardiovascular
Lungs - instead of Respiratory

For ROS, he does this
Head (NOT an element of ROS but he insists on listing it)
Skin (Instead of using the heading listed in the CPT manual as Musculoskeletal)

Thanks

 

[Skymom]

To the best of my knowledge, using the CPT headings is not a requirement, and it is acceptable to infer that the CV system has been assressed when heart is checked, and the respiratory system has been addressed when lungs are checked.

HEENT is acceptable per CMS guidelines.

Head is a body system per 95 guidelines.

Not sure what to tell you about his documentation of PFSH.

Here are CMS guidelines for both the 95 and the 97 versions.


https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/95Docguidelines.pdf

https://www.cms.gov/Outreach-and-Ed...N/MLNEdWebGuide/Downloads/97Docguidelines.pdf

https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Happy holidays - hope this helps!

 

[thomas7331]

To the best of my knowledge, using the CPT headings is not a requirement, and it is acceptable to infer that the CV system has been assressed when heart is checked, and the respiratory system has been addresses when lungs are checked.

I agree, and there is no compliance issue that I'm aware of regarding the manner in which a provider organizes, formats, or otherwise documents their medical records as long as the information is accurate, legible, and properly authenticated. As long as the code levels correctly represent the documentation of the work done, I would agree with your administrator that this isn't a compliance issue. I'd also just note that the CMS guidelines for E&M documentation are just that: guidelines and not regulatory requirements. Although in the world of coding and auditing we and our payers rely heavily on these, they are not in fact written into law and therefore allow a great deal of latitude for individual interpretation.

 

[REGINALD068]

Good morning and thank you both for your feedback. However, my statement did not infer "Head" is NOT a part of body areas/organ systems. I stated, it is NOT a part of ROS.

Thanks again!