Wiki PFSH - Reviewed

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AmandaW

AmandaW

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Can the documentation for the PFSH just say Reviewed, IF there is intake paperwork scanned in the chart that the patient filled out? In the real world, will an auditor not give credit there or would it be ok if there really is paperwork filled out by the patient and scanned in their chart?
 
The following E&M Guidelines went into affect on 01/01/19

  • When relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.

  • Practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.

Based on these guidelines if the provider indicated that they were reviewed and verified then this would be acceptable.
 
This is sometimes even for a new patient. The nurse or scribe or whoever might just have Reviewed right there by the PFSH. The word 'Reviewed' only. I was wondering if that is ok as far as being audited, would the auditor look at the intake papers filled out by the patient right there in their chart in the EMR? And/or if we are audited and need to send in records, would it be acceptable to send in the note along with the patient's paper they filled out?
 
It is appropriate for a nurse or MA to obtain the PFSH on the date of service and document the information for the medical records. In these cases per CMS...

  • The Review of Systems and the PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, the physician must add a notation supplementing or confirming the information recorded by others.

Your question in regards to the whether or not "reviewed" is acceptable or sufficient to meet the requirements brings us to a grey area. You will hear comments from both sides stating that this is enough to meet the guidelines and others who will state that this is not enough.

My rule of thumb is if this is a grey area, let's get back into the black and white of the matter. So in this case I would use this as an opportunity with the physician to discuss the issue and your concern. Possibly a meeting in the middle would be sufficient such as wording, "Reviewed and confirmed as noted - No changes." Remember that while we are the coders ultimately the responsibility for all billing lies with the physician and their license. So since clearer instruction is not available from CMS (grey area), if the provider is adamant that "reviewed" is sufficient, then documented your conversation for your records and proceed as instructed.
 
Would this also apply to a first time seen patient or just for a follow up?
 
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