KStaten
Guru
Hello Everyone!
I am trying to put a table together to describe components of a medical document for a typical outpatient setting office visit and list who (per Medicare guidelines) has permission to document each one. In other words, in order to correctly bill under the physician, what components must he or she document him/herself?
Here's what I've drafted thus far... Does this look correct? If not, what changes do I need to make? THANKS!
[UPDATE: It has been pointed out (and understood) that the wording in this original table has been "more confusing than helpful." So, for clarification purposes, my poor choice of words, "PERMISSION TO DOCUMENT," was intended to mean Medicare allows this healthcare member to document AND Recognizes his/her documentation as counting towards the E/M level of service being billed. This is also referring to when strictly billing under the physician -- not incident-to billing-- as stated above in the original post. Additionally, this is with the assumption that scribes may also physically document the information provided, but that the content of the documentation must be supplied by one of the healthcare members listed. I have added this edit (and set it aside in brackets) to my original post and have left the remainder of the post in its original form for coherence of follow-up posts. Thank you, and, again, I apologize for the confusion! I appreciate all of your help and guidance!]
Thank You in Advance!
Kim
I am trying to put a table together to describe components of a medical document for a typical outpatient setting office visit and list who (per Medicare guidelines) has permission to document each one. In other words, in order to correctly bill under the physician, what components must he or she document him/herself?
Here's what I've drafted thus far... Does this look correct? If not, what changes do I need to make? THANKS!
[UPDATE: It has been pointed out (and understood) that the wording in this original table has been "more confusing than helpful." So, for clarification purposes, my poor choice of words, "PERMISSION TO DOCUMENT," was intended to mean Medicare allows this healthcare member to document AND Recognizes his/her documentation as counting towards the E/M level of service being billed. This is also referring to when strictly billing under the physician -- not incident-to billing-- as stated above in the original post. Additionally, this is with the assumption that scribes may also physically document the information provided, but that the content of the documentation must be supplied by one of the healthcare members listed. I have added this edit (and set it aside in brackets) to my original post and have left the remainder of the post in its original form for coherence of follow-up posts. Thank you, and, again, I apologize for the confusion! I appreciate all of your help and guidance!]
MEDICAL RECORD | PERMISSION TO DOCUMENT | PERMISSION TO DOCUMENT |
---|---|---|
COMPONENT | NEW PATIENT OR ESTABLISHED PATIENT with NEW COMPLAINT | ESTABLISHED PATIENT with ESTABLISHED COMPLAINT |
Chief Complaint (CC) | Ancillary Staff, Physician, or PA | Ancillary Staff, Physician, or PA |
Review of Systems (ROS) | Ancillary Staff, Physician, or PA | Ancillary Staff, Physician, or PA |
Past, Family, and Social History (PFSH) | Ancillary Staff, Physician, or PA | Ancillary Staff, Physician, or PA |
Vital Signs | Ancillary Staff, Physician, or PA | Ancillary Staff, Physician, or PA |
History of Present Illness (HPI) | Ancillary Staff, Physician, or PA | Ancillary Staff, Physician, or PA |
X-Ray / Image Interpretation | Physician | Physician |
Physical Exam | Physician | Physician or PA |
Plan of Care | Physician | Physician or PA (if continuing same plan of care) |
Procedure | Physician | Physician or PA |
Thank You in Advance!
Kim
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