Wiki Vital signs

[nonadianne]

I have a NP who does SNF visits. She has her own provider number. She said that she does not have to have vital signs in order to
bill for her visits. Lately none of her visits have vitals and all notes read the same. The only thing that changes is the residents name and
their diagnosis. She lists no medication and in my opinion the visit is not billable, because she has no chief complaint and the resident is always in
no acute distress. Also her plan is the same on all, will continue current meds and continue to follow.

Am I wrong on saying that there is no medical necessity and that I can not bill for these visits when she says they are at least a 99307.
Please need opinions right away.

Thanks

 

[mitchellde]

This has the sound of a cloned note. She has predicated a note and pastes it to every patient changing only he name and date. You should go read up on Medicares view of cloning. This is not a good thing to be doing and Medicare will not be pleased. In addition if this is true then it also means she has made the progress note before she even sees the patient. Again Medicate says you cannot create a chart note in advance of seeing the patient. Here is an excerpt from the Medicare FAQ section I found regarding cloning:
Documentation is considered cloned when each entry in the medical record for a patient is worded exactly alike or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from patient to patient. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments.

 

[thomas7331]

Vital signs are not required to bill for the visit - that is just one element of the exam. But otherwise I agree with your assessment and with Debra's post. A chief complaint is required for all E&M codes, the documentation must support the medical necessity of the visit, and cloned notes will put the charges at risk in an audit. A little documentation coaching would probably take care of this. 99307 is low level charge that should be easy to support and needs very little documentation to meet the minimum requirements. At the very least, the provider needs to add a chief complaint that says why the patient is being seen - it could be as simple as 'monthly f/u for CHF' - and some basic elements history and exam that are specific to that patient and not cloned from another note.