Wiki Frustrated, and in need of advice

[Melonyr]

I am a newly certified CPC and my methods are being attacked where I work regarding e/m services. Maybe I need some more info/training on this but please tell me if I am doing this correctly. I work on the payor end, and am being told, by someone not certified, that I am doing this incorrectly.

The provider is documenting in their notes that a complete ROS is being done, in addition to an extended HPI and pertinent PFSH, The exam is expanded problem focused and the MDM shows 3 dx codes, no testing additinal data, but on the table of risk the patient is on narcotic pain meds, which is moderate risk if you use the 2 of 3 method. Since is it an established patient and they have met 2 of 3 I have stated that this is a 99214.

The person that is attacking my coding is stating that the ROS is being done too much, how do we know that it was done, it isn't listed in the exam. He isn't really having that done on every visit.

Now, my understanding is that I am to code the notes for that date of service, not look at every visit that the patient has had and "decide" that it wasn't really done and reduce the level of visit, but maybe I am wrong.

Please help and tell me if I am doing this right

 

[Love Coding!]

Hi Melony,

There are 2 sides to that.

1. You are not the clinician so whether or not they are actually doing a complete ROS is not up to you but up to the clinician. Get familiar with the diagnosis that you code, example if a pt is being seen for hypertension, obviously Cardiovascular would be listed under ROS. In terms of looking at the exam and ROS to reflect one another, it all depends on what the patient is being seen for. If a patient is being seen for lets say ear infection, it would not make sense to review say Musculoskeletal.

2. Education, education, education. Ask your physicians why do they list all ROS for every visit, you will be surprised to see that most will not know the answer to that question.

You're doing fine, keep going and take negative criticism as something positive, anywhere we coders can learn and expand our knowledge!

Good luck!

 

[Melonyr]

Thanks, here is the issue, I work for a worker's compensation carrier, the diagnosis is a back injury, stenosis of the spine and a couple of other realted diagnosises. I can't really ask the provider as I do not work for his office.

Thanks again

 

[Melonyr]

Here is my other issue, the same person that is attacking my coding is stating that I should be basing my coding on whether or not it shows the ROS in past visits. I am not supposed to look at evey visit and say well, since this is listed for all of the visits this year it wasn't done at each one am I? That is what she is trying to tell me to do, which is not what I was trained on.

Once again, HELP

 

[mitchellde]

Melony,
You are correct you do not look back at every visit. The providers documentation for each encounter gets to stand for that encounter. ROS is a part of history and can be collected by anyone in the office or a patient answered questionair, however the physician must document that this was discussed and reviewed with the patient. The E&M guidelines do state that the ROS does not have to be captured on each encounter, however to bring a prior recorded ROS forward the physician must note the location and date of the prior ROS (in my office notes from 11/01/09) and that the ROS was reviewed with the patient and note any changes or updates. Once again ROS is history and as such does not have to be redone but must be reviewed and noted. I hope this helps a little bit.