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Documentation Question E/M

  1. #1
    Default Documentation Question E/M
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    We had a client to come into clinic for quick f/u for her meds. It was then determined that she needed to speak with our MD regarding issues, so he met with her for a 99214. The CNS ended up writing her regular note and went on about her day.

    The M.D./nurse did not make me aware of this until 3 days after the fact (before billings have gone out), so my question is:

    A. Does the M.D. add an addendum to the Nurse note and we bill for only the M.D. time (as i know we cannot bill 2 e/m on same day)
    ~OR~
    B. Does M.D. write his own note and reference the nurse note for further documentation?

    I am concerned because this was not documented by the M.D. immediately that we "may" be in trouble with it. In the CNS note, it is documented that our M.D. did come in and meet with client on urgent basis, she noted all medication changes per M.D. etc, however, M.D. did not make any of the note himself on the day client was seen.

    Help?
    Last edited by jcochran; 08-08-2011 at 02:35 PM.

  2. #2
    Default
    Quote Originally Posted by jcochran View Post
    We had a client to come into clinic for quick f/u for her meds. It was then determined that she needed to speak with our MD regarding issues, so he met with her for a 99214. The nurse ended up writing her regular note and went on about her day.

    The M.D./nurse did not make me aware of this until 3 days after the fact (before billings have gone out), so my question is:

    A. Does the M.D. add an addendum to the Nurse note and we bill for only the M.D. time (as i know we cannot bill 2 e/m on same day)
    ~OR~
    B. Does M.D. write his own note and reference the nurse note for further documentation?

    I am concerned because this was not documented by the M.D. immediately that we "may" be in trouble with it. In the nurse note, it is documented that our M.D. did come in and meet with client on urgent basis, she noted all medication changes per M.D. etc, however, M.D. did not make any of the note himself on the day client was seen.

    Help?
    Whoa...Okay - a few things:
    1. If it's just a nurse, and not an FNP taking the notes, they can't be used for E/M. The provider (eg, physician or non-physician practitioner) must document the HPI, exam, and MDM personally (or by use of a scribe) - they can't just piggyback off of someone else's work. The services must be within the nurse's scope of practice; if they're not licensed to provide E/M services, then they can't provide E/M services
    2. If this does qualify for 'incident-to' billing, you'd only submit one claim for the doctor, not one for each of them.
    See page 12: http://www.trailblazerhealth.com/Pub...ncident_to.pdf
    "Requirements for “incident to” are:
    The services are commonly furnished in a physician's office.
    The physician must have initially seen the patient.
    There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
    The physician has an active part in the ongoing care of the patient.
    Direct supervision in the office setting does not mean that the physician/non-physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction while the aide is performing services....
    The only NPPs who may bill E/M services (above the level of 99211) under the “incident to” criteria are NPs, CNSs, PAs and nurse midwives.
    To ensure proper reimbursement according to the fee schedule, Medicare requires that documentation submitted to support billing “incident to” services must clearly link the services of the NPP to the services of the supervising physician."
    3. A follow-up for chronic conditions/medication refills may not be billable as a level 4 E/M; you should check with your MAC over what they considered medically reasonable and necessary. Trailblazer, for example, requires that at least 3 distinct chronic conditions be evaluated (mentioned in the HPI), and treated (Mentioned in the MDM), in order to report a 99214 or 99215, and they have restrictions on the frequency of which follow-up visits are allowed. (Usually once every 3 months at most).

    You may want to discuss changing the billing practice in your office, to one where you code off of the chart, as opposed to a superbill, to avoid these situations in the future. Something that's incorrectly marked on the superbill, or wasn't documented properly, could cause a sticky compliance issue, if the right hand doesn't know what the left hand's doing. You may find that it cuts down on claim denials, and that you catch charges that the physician might have forgotten to bill, so the benefits definitely outweigh the slight drawback of having to wait a little bit longer to enter the day's charges. Hope that helps!

  3. #3
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    Quote Originally Posted by btadlock1 View Post
    You may want to discuss changing the billing practice in your office, to one where you code off of the chart, as opposed to a superbill, to avoid these situations in the future. Something that's incorrectly marked on the superbill, or wasn't documented properly, could cause a sticky compliance issue, if the right hand doesn't know what the left hand's doing. You may find that it cuts down on claim denials, and that you catch charges that the physician might have forgotten to bill, so the benefits definitely outweigh the slight drawback of having to wait a little bit longer to enter the day's charges. Hope that helps!
    Ok, To clairify, this was CNS that took the information, and the client did initially come in for only a 99211 (sorry for the confusion on that) and we do indeed meet the criteria for incident to billing for her (thanks for making sure). However, when M.D. saw client, he ended up changing 2 of her med's as well as spending an extended period of time with her regarding her current meds vs. her new meds, as well as counseling her regarding her diagnosis and how the change in her meds will effect that.

    And I completely agree with what you're saying about "if the right hand doesn't know what the left hand's doing." (this has been a very real problem since the implementation of our EHR, where we use schedule based billing instead of superbill or charge ticket, and we are still working on resolving these workflow issues).

    My question is basically, my M.D. wants to reference the CNS's notes, instead of writing his own completely new chart note (issues with the way our EHR works again). I will just make it clear to M.D. that he does need to write a full chart note.

    I am wondering if that is going to cause any issues as far as M.D. not writing the chart note on the day of the visit.
    Last edited by jcochran; 08-08-2011 at 02:34 PM.

  4. #4
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    I see....He should mention the notes specifically, and update or add any info, where it's needed. Pretty much the only info that can be copied forward from CNS notes, are ROS, PFSH, and vitals for the exam. He should document his own HPI. Our EMR pulls the nurse's notes forward and sticks them under the heading "Chief Complaint", (which annoys me beyond words), and sometimes the provider will only say "Agree with above" - I don't count it, unless I can reasonably believe that he did some fact-finding of his own, which is usually indicated by extended HPI notes.

    Don't you love how the people who created these EMR systems seem to have no knowledge of coding whatsoever? If you're going to plug all of the rules in there, at least know what they are first! Drives me up the wall as an auditor...Good luck!
    I am wondering if that is going to cause any issues as far as M.D. not writing the chart note on the day of the visit.

  5. #5
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    Milwaukee WI
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    Default Counseling/Coordination of care?
    The physician must document his own note. However, if the majority of the visit was spent in counseling/coordination of care, he can document that vs the 3 key elements.

    To bill based on time spent in counseling/coordination of care, the physician must document
    1) total time spent face to face with the patient
    2) time spent in face-to-face counseling/coordination of care (must be more than 50% of total time)
    3) summary of what was discussed.
    The level of service is determined by the total time spent face-to-face.

    EXAMPLE: Chief complaint: HTN not responding to medication.

    I spent 25 minutes with Mrs Patient, all of it in counseling/coordination of care, discussing the changes to her medication regimen. We covered the reasons for change, the expected outcome of new regimen, and potential side effects of new medications. All her questions were answered to her satisfaction.


    Hope this helps.

    F Tessa Bartels, CPC, CEMC

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