Neurology & Pain Management Coding Alert

Hint: Forms and procedures smooth the process 

Teaching your neurologist to accurately document a patient's HPI (history of present illness) can make his job easier and your coding more accurate down the road. Try these tips to help get a better picture of your patients- conditions:

- Get information up front. Your appointment scheduler can get some details from patients when they call for an appointment.

- Enlist help from nurses or nurse assistants. Some groups have their nurses obtain the patient's vitals and chief complaint when they take the patient to a room, so this documentation is handled for the provider.

- Use templates to ensure providers don't miss documenting any of the E/M visit components. -Since we-ve gone to templates, it's gotten easier because they just have to make a check mark,- says Kathy Campbell, CPC, a biller in Bloomington, Ind.

- Let patients help document their condition. -If you use a good template, the patient can fill out a portion of HPI,- says Jennifer Gero, a coder and billing specialist in South Carolina. -Who else knows their symptoms better than the patients?-

-We have to remind our providers that they may use previous dates of service, history form, reason-for-visit forms, and other documentation as part of the HPI,- says South Carolina coding consultant Julee Shiley, CPC, CCS-P, CMC. -They sometimes forget that this can be counted and may lower the appropriate E/M level if the reference is made but not documented properly.-

Just getting all the required documentation for the highest level of HPI possible can be a challenge,  Campbell says. But the extra effort you put into educating providers about documentation can mean a significant change in your group's bottom line.