Document consistency

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I've got a bit of an issue that's come up with a couple of our providers. They both perform DOT exams for the National Registry and in our clinic, these are always (99.99% of the time) also considered the patient's annual physical. A lot of the time, the cc or HPI will say the patient present for DOT and annual physical. That's great, I'll bill it as a physical with Z00.0x. But an increasing number of visits are just saying they present for DOT. Then the assessment will include the Z00.0x code. In this case, I task asking that if it was also their physical, to please include that in the CC or HPI. I do this because I don't want the note to start out saying the patient is there for service X and then in the assessment indicate it's service Y. Thismakes it conflict with itself and I worry it will cause issues during audits, especially since insurance isn't going to want to pay for a DOT exam.

We've recenty gotten some lash back from the providers, with one saying "Why isn't indicating it's a physical in the assessment enough? Why do I have to also put it in the HPI?" The other wants to make it clinic policy that all DOTs are automatically considered annual physicals, so they can stop worrying about what the HPI says. I've been trying to find documentation to support my stance that the note needs to be consistent, it can't conflict with itself, and I've been surprised at really not finding anything either in coding guidelines or online talking about it. I'm hoping you all could weigh in on whether I'm being too picky about this (is having the Z00.0x code in the assessment enough evidence that it's also an annual physical?) and if I'm not, do you know where I could look to support my argument? Thank you for any help!
 
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Chelle-Lynn

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This issue can be a little confusing especially for the providers. They look at things from the medical point of view and do not see the difference between a DOT physical (Z02.-) and an annual physical (Z00.-). It would make sense that if the providers in your office consider these services to be one and the same that they update the policy to make sure that both the DOT and annual physical is listed in the CC line. In most cases this line item is completed by the MA or the nurse that rooms the patient and it would be an easy update to their policy.

While we as coders tend to be a little picky, it is always a good idea to clear state the reason for the visit to avoid grey areas in the future.
 
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