Meeting medical necessity in the OV note

[fltbaroque]

Does this meet medical necessity?
A patient fills out paperwork and there are sections labeled "family history", "past medical history", "social history" and "review of systems".
The doctor states in his note, "I went over patient's history and review of systems and it is in the chart".
How can you level a visit with this? There's really no way to tell what the doctor went over with the patient.

 

[Orthocoderpgu]

I worked in an office one time and had a similar issue. I would say it does not for this reason: Chances are that the patient completed a complete ROS at the time along with the PFSH. Nothing wrong with that. However, you need to know how many of the PFSH was done, and which ones. Going forward, this will change and not every visit will require a PFSH and the ROS will change as well. You will not need to go over the complete ROS on every follow up visit. Plus you don't know which ROS were normal or abnormal. And those will change over the course of treatment too so these will need to be adjusted and documented as the treatment goes on. This is one reason why CMS states that MDM is the overarching factor in determining an E/M level. Chances are your doc will want credit for a "Complete" history since they will review that initial PFSH and ROS form. They need to change the PFSH and ROS with time as the medical condition is being followed. Just doing a complete ROS every time is not compliant and auditors may not give you credit for a ROS if all your doing is referring back to the one that the patient initially filled out on their first visit.

 

[jdibble]

Does this meet medical necessity?
A patient fills out paperwork and there are sections labeled "family history", "past medical history", "social history" and "review of systems".
The doctor states in his note, "I went over patient's history and review of systems and it is in the chart".
How can you level a visit with this? There's really no way to tell what the doctor went over with the patient.

It may not be a preferred method for coders, but it is acceptable to use the PFSH and ROS information from patient forms (or recorded by ancillary staff) to qualify the History, however the documentation in the physicians note for that date of service must show that the doctor reviewed those forms and state where in the chart that information was located. We also require that the physician sign and date the form to show that it was reviewed. If it is a patient form, you would need to review those forms as well as the note to make sure all of the information was completed or enough was done to qualify for a complete ROS or PFSH depending on the level being billed, otherwise you would chose the level based on what areas the patient did complete (i.e. if the did not fill in the Family history and the doctor didn't mention any family history in his note, than you could not count the PFSH as complete).

If this is a follow-up visit, the physician can review those forms with the patient and make a statement that it was reviewed and nothing has changed or document any thing that has changed and still qualify for a complete ROS and PFSH if there was originally enough information for that level. Again, we have our physicians sign and date the document each time that they re-review this form with the patient in order for it to count.

Keep in mind that if your physicians do their charts this way that anytime there is a request for the patient's records (such as in an audit) you must include the patient ROS/PFSH forms with the note for that date of service - otherwise they will not see that a complete ROS or PFSH was done.

It would be so much easier if the doctor just included the appropriate information in the chart note for each date of service!!