Help! Documentation >50% counseling/cc

cadillacmtn

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My understanding is that when billing on time, and >50% of a visit was dominated by counseling/coordination of care, the key components of HPI, exam, MDM do not have to be met. Our medical director has come up with a form used for palliative care consults where the hospital attending has requested our providers come in and do an inpt goals of care consult: pt has life-limiting illness and major decisions must be made regarding treatment vs quality of life, etc. Lengthy discussions take place with pt/family re disease progression, EOL decisions, treatment options, and provider must educate pt/family about realities of prognosis, etc.

So.... this form is tailored so provider can give summary of what was discussed, who was present, who is making medical decisions. There is also a place for pt vitals, review of labs, and the F2F time in patient room, along with floor time, doc time. However, there is no exam documented, and no hpi other than assessment of terminal/comorbid conditions. Are we ok on this, or do we still have to have completely documented the exam HPI in addition?

The guidance from CMS is pretty limited, other than that the level is based on time spent, and required documentation of F2F, total inpt time, summary of discussion, and stmt re: >50%........ There are countless reputable websites devoted to EM that indicate (or interpret) that the key components used to code on complexity are not required when billing on time.

Please advise!
 

linc11

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I agree, this is certainly a vague area with CMS. Other than stating your progress note sould reflect the nature of the counseling or coordination of care you provided, nothing is mentioned about documenting the HPI or exam. At least that I can find.

In this instance we are often times left to our educated resources to come up with an answer. Personally, I like an article that was written by a physician who states "If a physician spends more than 50 percent of a face-to-face visit counseling or coordinating a patient's care, the physician can code the visit on the basis of time, even if the history, exam or medical decision making elements are lacking." The link to the article is www.aafp.org/fpm/2003/0600/p27.html if you are interested.

Hope this helps! :)
 

cadillacmtn

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Thanks Lisa, good article. It is SO frustrating that most of the MACs do not address/interpret these fine lines, but you are at their mercy in an audit!!!! Outside of the MACs, the consensus seems to be that key components are not mandated when the visit is based on time.
 
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