# documentation from previous E/M



## Anna Weaver (Mar 18, 2009)

We have a claim that rejected the protime for medical necessity from a visit in 2009. When we asked for the documentation to check for diagnosis, there is nothing there to indicate that a protime was done on that date. No dx will pass for medical necessity and can't find any way for this to pass. We contacted the office again, they said the patient was on chronic anticoagulation therapy. We told them there is nothing indicated on the chart on that date of service. They responded with a note that they have a separate sheet indicating patient problems and it's listed there and sent this to us. They also sent 2 previous office visits indicating anticoagulation therapy. None of these are referenced on the medical record for the date of service we need. The patient problem sheets are not signed by the physician. They have a flow sheet indicating date of service, dosage, lab date and result for that date of service, again not signed by the physician. They have a medication reconciliation sheet, again not signed by physician. Is any of this admissable for us without being referenced in some way in the record for that visit for that date of service? Can we go ahead with this protime charge from previous dates of service? 
Any help would be greatly appreciated. 
Thanks!


----------



## ARCPC9491 (Mar 18, 2009)

I've always been taught that each date of service must stand alone to be billable. If there is nothing in the chart for the specific date of service billed, I feel as if they would have to eat it. This could be used for education too. It's important for a practice to know they are losing money from poor documentation or failure to provide documentation, in your case. 

Hope that helps.


----------



## Anna Weaver (Mar 19, 2009)

*E/M*

Thanks for your response. That was what I was taught also, but just wanted to make sure. The office manager is questioning my advice. Just wanted to confirm before we went further with this.


----------



## kbarron (Mar 19, 2009)

The stand by statement" If it is not documented, it is not done".


----------



## dmaec (Mar 19, 2009)

is it a "standing order" though?  we have many "standing orders" for our protime labs.


----------



## ARCPC9491 (Mar 19, 2009)

It may be a standing order, but just because they are suppost to come once a week, doesn't mean they actually came... and with no documentation relevant to the date, you can't prove they were actually there and had this service.


----------



## dmaec (Mar 19, 2009)

the "standing order" which is typically good for a year  - "is" the documentation supporting the service.  and, she does have documentation (proof) of service.. just not a dx. (unless it's on the standing order)  
_***They have a flow sheet indicating date of service, dosage, lab date and result for that date of service***_

but actually - I'm not sure this is a lab only... but if it is, and there's a standing order, it can indeed be billed/coded according to the standing order. the "proof" of service is the result of the lab for that date of service.


----------



## ARCPC9491 (Mar 19, 2009)

I have to respectfully disagree that you can bill/code according to the "standing order". Just because something has been ordered doesn't mean it was done.  Just because a patient was "ordered" to have a test done on the second Monday of every month or what have you, doesn't mean they did...  You bill/code from the results - proof that the patient followed your order.

But here's an idea -- why don't you query the physician and ask them to complete the medical record!


----------



## dmaec (Mar 19, 2009)

ARCPC9491... I agree, you can't code anything from standing orders alone.. *shrugs*.. that's a given,... obviously, you can't code anything that wasn't actually done...but I thought I made that clear in my last post, maybe not...?

but again, we might be talking apples and oranges here... I'm talking IF this is a returning lab, protime, recurring, standing order sort of issue... AND obviously services were rendered... you can pull the dx for the labs from the standing order.  (that's all I'm saying)

*__________________*
see previous post:

the "standing order" which is typically good for a year - "is" the documentation supporting the service. *and, she does have documentation (proof) of service..* just not a dx. (unless it's on the standing order) 
****They have a flow sheet indicating date of service, dosage, lab date and result for that date of service*** 

but actually - I'm not sure this is a lab only... but if it is, and there's a standing order, it can indeed be billed/coded according to the standing order. the "proof" of service is the result of the lab for that date of service
___________________


*(this is from orignal post, and results ARE proof service was provided, isn't it? or do you feel they come up with results for services NOT rendered?)


----------



## ARCPC9491 (Mar 19, 2009)

*but again, we might be talking apples and oranges here... I'm talking IF this is a returning lab, protime, recurring, standing order sort of issue... AND obviously services were rendered... you can pull the dx for the labs from the standing order. (that's all I'm saying)*


I agree! I think I might have misunderstood in some strange way... somethings need to be put in different words for my brain to work sometimes


----------



## Anna Weaver (Mar 20, 2009)

*standing orders*

I believe this is a standing order, the blood is drawn in the office. Nothing other than the office visit is signed by the Dr. None of the patient problem lists, not the lab result, nothing but the OV, and it doesn't list the protime. That's where my problem lies. It's all over the chart that the protime is needed, and done, but no where is it signed. They feel they are okay with their documentation because it's in the chart. The previous 2 office visits do list the long term anticoagulation therapy, but not this particular visit. When we got a rejection on the protime, that's when we discovered the problem list issue. When we asked for documentation, it does not support a protime. As I said before, I was always taught that each visit should stand alone. The protime can be drawn on a standing order, and yes, is good for a year, BUT, shouldn't it be listed in the chronic conditions on the office visit notes that the patient had this done? Wasn't listed on the lab section either. Not that they discussed results, had anything drawn etc. Thanks everyone for your replies. I learn a lot from this forum!


----------

