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Evaluation and Management (E/M) Service: Face-to-face Documentation
http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD
Novitas Solutions in concert with the Centers for Medicare & Medicaid Services (CMS) is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern is denial of certain E/M services due to insufficient documentation; specifically, documentation of a face-to-face encounter.
Professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report E/M services by a specific CPT code.
Face-to-face time is defined as only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination and counseling the patient.
Below are examples of services continually being denied because the medical record documentation is missing detailed information to support the patient had a face-to-face encounter to meet the definition and/or requirement of the service being billed.
Procedure code 90960 is defined as an ESRD related services monthly for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month.
Procedure code 99212 is defined as office or other outpatient visit for the evaluation and management an established patient, which requires at least 2 of 3 key components (problem focused history, problem focused exam, straightforward medical decision making). Usually the presenting problems are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
Procedure 99231 is defined as subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 3 key components (problem focused interval history, problem focused exam, medical decision making that is straightforward or of low complexity). Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit.
Procedure 99238 is defined as hospital discharge management, 30 minutes or less. This is considered a professional service and as such documentation must support that a face-to-face service occurred by a physician and other health care professional.
In order to support the requirements necessary to verify that face-to-face services occurred, clear and concise medical record documentation is critical. E/M services vary in several ways, such as the nature and amount of physician work required, type of service, place of service and the patient status. General rules of documentation should be followed to support the services billed. These rules are further defined in the 1995 guidelines, 1997 guidelines and the CMS Evaluation and Management Guide available in the Coding Instructions within the Evaluation & Management Center of our website.
Remember, if it isn?t documented, it wasn't done.
Evaluation and Management (E/M) Service: Face-to-face Documentation
http://www.novitas-solutions.com/webcenter/faces/oracle/webcenter/page/scopedMD
Novitas Solutions in concert with the Centers for Medicare & Medicaid Services (CMS) is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern is denial of certain E/M services due to insufficient documentation; specifically, documentation of a face-to-face encounter.
Professional services are those face-to-face services rendered by physicians and other qualified health care professionals who may report E/M services by a specific CPT code.
Face-to-face time is defined as only that time spent face-to-face with the patient and/or family. This includes the time spent performing such tasks as obtaining a history, examination and counseling the patient.
Below are examples of services continually being denied because the medical record documentation is missing detailed information to support the patient had a face-to-face encounter to meet the definition and/or requirement of the service being billed.
Procedure code 90960 is defined as an ESRD related services monthly for patients 20 years of age and older; with 4 or more face-to-face visits by a physician or other qualified health care professional per month.
Procedure code 99212 is defined as office or other outpatient visit for the evaluation and management an established patient, which requires at least 2 of 3 key components (problem focused history, problem focused exam, straightforward medical decision making). Usually the presenting problems are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
Procedure 99231 is defined as subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 3 key components (problem focused interval history, problem focused exam, medical decision making that is straightforward or of low complexity). Usually, the patient is stable, recovering or improving. Typically, 15 minutes are spent at the bedside and on the patient's hospital floor or unit.
Procedure 99238 is defined as hospital discharge management, 30 minutes or less. This is considered a professional service and as such documentation must support that a face-to-face service occurred by a physician and other health care professional.
In order to support the requirements necessary to verify that face-to-face services occurred, clear and concise medical record documentation is critical. E/M services vary in several ways, such as the nature and amount of physician work required, type of service, place of service and the patient status. General rules of documentation should be followed to support the services billed. These rules are further defined in the 1995 guidelines, 1997 guidelines and the CMS Evaluation and Management Guide available in the Coding Instructions within the Evaluation & Management Center of our website.
Remember, if it isn?t documented, it wasn't done.