Question Signature still needed for ROS and HPI?

Cheezum51

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I realize that the new guidelines for the E/M office visit codes state that a "medically appropriate history and exam" is required now. A question for those of you who do auditing: Since anyHPI and ROS done for an exam may have been done entirely by staff, do you feel it's still necessary for the provider to acknowledge in writing/note that they have reviewed the HPI and ROS for an exam as they were required to do prior to this year?
 

Orthocoderpgu

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The only thing that has changed is that the HPI/ROS & Exam are not being used as "Key Components" to determine E/M level. The physician will still need to sign off on work performed by ancillary staff. With electronic medical records the physician can review the HPI/ROS that the ancillary staff has performed in about one minute. It could not be easier or less time consuming.
 

Cheezum51

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The only thing that has changed is that the HPI/ROS & Exam are not being used as "Key Components" to determine E/M level. The physician will still need to sign off on work performed by ancillary staff. With electronic medical records the physician can review the HPI/ROS that the ancillary staff has performed in about one minute. It could not be easier or less time consuming.
Thank you. My thoughts exactly but I've been receiving some push back on this from others.
 

thomas7331

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If it's not required to determine the E/M level, then what is it required for? I don't see how a payer could disqualify a note for payment based on this if it is no longer a factor in code determination - the payer would not have a case. Even if they disqualified the ROS, for example, for not being documented properly by the provider, the code still stands based on the MDM or time.
 

Cheezum51

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If it's not required to determine the E/M level, then what is it required for? I don't see how a payer could disqualify a note for payment based on this if it is no longer a factor in code determination - the payer would not have a case. Even if they disqualified the ROS, for example, for not being documented properly by the provider, the code still stands based on the MDM or time.
Those "signatures" weren't required, to the best of my knowledge, to determine E/M level previously either. To my understanding, they were required to confirm that the provider had taken/reviewed the HPI and ROS, just as the signature on an I&R or at the end of a record is used to determine/confirm who the provider was that did the exam and I&R.

I'm not trying to argue that they still are mandatory, just trying to find out if anyone has read anything which states that they are. However, I don't feel that still requiring the provider to confirm that they have reviewed those sections of the record are an undue burden. To me, it shows that they have paid attention to the patient history as they do their exam and come up with their assessment and plan.

Tom Cheezum, OD, CPC, COPC
 

thomas7331

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Those "signatures" weren't required, to the best of my knowledge, to determine E/M level previously either. To my understanding, they were required to confirm that the provider had taken/reviewed the HPI and ROS, just as the signature on an I&R or at the end of a record is used to determine/confirm who the provider was that did the exam and I&R.

I'm not trying to argue that they still are mandatory, just trying to find out if anyone has read anything which states that they are. However, I don't feel that still requiring the provider to confirm that they have reviewed those sections of the record are an undue burden. To me, it shows that they have paid attention to the patient history as they do their exam and come up with their assessment and plan.

Tom Cheezum, OD, CPC, COPC
I agree with you - I think it's good for documentation quality and a worthwhile thing to ask providers to do. I guess I'm coming at it from the coders' side though and saying I wouldn't cite it as a coding error if that particular 'requirement' wasn't met (unless so directed by the organization conducting the audit). At most, I'd make it an 'FYI' and give feedback to the provider as an opportunity for improvement. Under the old guidelines, we'd have to consider it an error if the HPI and/or ROS that wasn't documented correctly had been counted toward the level that was chosen and resulted in a different code.
 

Cheezum51

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The FYI tact is what I take when doing informal audits for clients.

Tom Cheezum, OD, CPC, COPC
 

saddie2k

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According to AAPC's last workshop the rules for needing the hpi/hx reviewed hasn't changed. Like stated, they were not part of the actual level determination and were a separate requirement. Physician signatures/acknowledgement are still needed.
 
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