Wiki Help with provider documentation

[almayhew@notchvt.org]

I have recently taken over a position as a billing supervisor, the previous supervisor had told the providers with the new 2021 E/M changes, they did not need to document a history, PE, PMH, etc.... She told them they could document all of their medical decision making under the assessment. The problem I am having is I am having a hard time even finding any medical decision making being documented in the provider notes, therefore making it very difficult to code for them. The providers are very frustrated because they were told one thing, and I am trying to tell them that they need to do better and they feel I am being too picky. It was my understanding if you are doing a history, you should be documenting a history, etc. Does anyone have any suggestions for me to help explain this to them? Thanks in advance

 

[Orthocoderpgu]

Under the 2021 changes the CC,HPI, ROS & EXAM must still be documented, it's just not being used as a "Key Component" to determine the over-all level of the E/M since that will be based on either the time documented or the MDM. This is actually good new since especially with EMR it's too easy to have a Comprehensive history on every patient since the clinical staff is incorrectly filling in every box they see. I can't tell you how many thousands of E/M documentation I have seen with all fourteen ROS stating "Negative". Now instead of the clinical staff documenting every HPI & ROS element, they are now free to document only what's "medically necessary" and not be penalized for it.

 

[kimberlywatson]

Yes they definitely still need to document history/exam. The code levels state "a medically appropriate history and/or exam" as part of the description.