erinnbarber
New
Just curious to see how many people routinely send records back to clinicians if they're missing ROS or PFSH sections...?
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Wiki Sending Records Back to Clinicians
- Thread starter erinnbarber
- Start date
We will not send individual records back to the provider when these areas are not address. Generally we will review this in a one on one training or audit review with the provider. Not all services require and/or justify a ROS, PSFH, etc.
Keep in mind the goal is to ensure that we are billing for the services that are rendered and not "asking" for additional documentation to justify coding levels. It is a tricky area and I would warn against sending the records back as a regular routine. Instead I would work with the audit team or the compliance officer to address the importance of complete documentation as a training issue in ordered to be paid correctly for the services rendered.
Keep in mind the goal is to ensure that we are billing for the services that are rendered and not "asking" for additional documentation to justify coding levels. It is a tricky area and I would warn against sending the records back as a regular routine. Instead I would work with the audit team or the compliance officer to address the importance of complete documentation as a training issue in ordered to be paid correctly for the services rendered.
thomas7331
Guest
Agreed, the practices I have worked for would not routinely send records back to clinicians unless they contained an obvious error or were deficient in some way (for example, missing a signature, or insufficient information to assign a diagnosis code) that required a correction. Records would not be sent back based on audits of E&M levels - this information would be shared for educational purposes afterwards.
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CScholer
Contributor
I agree as well, the practices I have worked for have not sent providers messages for lack of ROS ,PFSH, etc. We have only sent back for "fatal flaws" such as missing signatures, co-signatures. We will educate our providers on proper documentation and such.