Wiki 1997 bullets

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CodingMari

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I need clarification - my providers have built in templates lets suppose patient comes in for a prescription refill and complaining of a cough

HPI is comprehensive because all ROS were marked off also medication was reviewed SH was reviewed and FH was also reviewed

Constitutional:3 vitals general appearance(2)
Eyes: perrla,fundi clear (2)
Ears, Nose, Mouth and Throat: nose appears, normal, no pharyngeal erythema (2)
Neck: no tender no masses no thyromegaly (2)
respiratory: normal respiratory effort,clear ausculation,clear to percussion(2)
Cardiovascular: no carotid bruits, RRR, no mrg,no peripheral edema (3)
Gastrointestinal (Abdomen) : abdominol soft tender, no guarding,no hernias (2)
SKIN: no rashes (1)
muscluloskelatal: examination of gait and station,no digital cyanosis or clubbing (2)

per 97 guidelines i am getting bullets meaning comprehensive exam???

Am I understanding this correctly??? I have reviewed CMS DG so please don't refer me to this link, I would really appreciated if someone explains this to me
 
You are correct, that for the exam portion of this visit the documentation above would allow for a comprehensive exam. 8 body parts/systems or more is comprehensive.
 
Thank you I tend to over analyse things and trying to break off that habit .

If the provider clicks all organ/systems in the EHR system and positive findings do we give them credit for the comprehensive exam when the patient CC: just refills and check up on a pneumonia. how do I code to determine the medical necessity piece?
 
Medical necessity is tricky. We are not medical providers and cannot determine medical necessity, that is up to the medical professional. However if you notice that a patient came in for a earache and the provider documents a comprehensive exam, it would be worth an open conversation with the provider in regards to possible medical necessity questions that may come up from the diagnosis and E&M combination.

We want to be a resource for the provider to help them avoid audits, refunds/recoupments, etc....but ultimately medical necessity is determined by the provider and it is their license at risk.
 
Yes, I get that ultimately that is determine by the provider but how do I as a coder make sure that i am awarding the correct level. i dont know if i am explaining my self correctly.
 
In a simplified statement....from your point of view as a coder, you will need to go by the leveling process of the History, Exam, and MDM (problem focused, expanded, detailed, and comprehensive). Medical necessity is the responsibility of the provider.
 
I appreciate you feedback.

But again how do I determine the correct level? do I look at the CC? Assesment? because if its determine by counting the bullets then the majority would be comprehensive. am I asking the correct question?

I even have a provider that ask will list all the ROS because she feels since is on the forms that she needs to ask all these questions!!

I need help! I got into coding because I have been a medical biller / Charge Master Analyst for 10 years but this coding is a whole different monster! I need mentoring!
 
You are in a difficult position, as you are correct, the provider should be completing their history, exam, and MDM based on the presenting problems and not completing all of the ROS because they are there to mark. In these cases you would need to look at medical necessity so as to not over code, which is tricky as we are not medical providers and that dances on the line of questioning their medical judgment.

In your situation I would recommend a few ideas...
1. Does your office contract with or have access to outside auditors who can audit the medical records and provide feedback to your providers on the documentation? Things like always marking all ROS will come up on these audits and can be addressed with the providers during these sessions.
2. Have your providers had training on documentation and the aspects of coding an E&M? Often times this helps the providers to understand what documentation is needed and how it translates to an E&M level.

It is important for the provider to understand both documentation and how it relates to coding to ensure appropriate documentation and leveling of the claim.
 
If you are using 1997 criteria for visit criteria then for the exam for this patient with a chief complaint of cough, then using the respiratory system criteria, this is a detail exam. he did not document all the elements in the shaded borders as is required for comprehensive exam. I count a total of 14 bullets which falls into detailed.
 
1. Does your office contract with or have access to outside auditors who can audit the medical records and provide feedback to your providers on the documentation? Things like always marking all ROS will come up on these audits and can be addressed with the providers during these sessions.
2. Have your providers had training on documentation and the aspects of coding an E&M? Often times this helps the providers to understand what documentation is needed and how it translates to an E&M level.


answer to question
2. I have explained to the providers to select code based of presenting problem but one provider even stated that the way the perform an exam is by checking the usual when they walk in a room which is E ENT RESP CARD GI, PSY usually 2 bullets per organ/system
1. private office

i like to help but need guidance
 
mitchellde said:
If you are using 1997 criteria for visit criteria then for the exam for this patient with a chief complaint of cough, then using the respiratory system criteria, this is a detail exam. he did not document all the elements in the shaded borders as is required for comprehensive exam. I count a total of 14 bullets which falls into detailed.
Click to expand...

what is the shaded borders? I have the 1997 guidelines and excuse my ignorance but I tend to get lost in all the paragraphs I am an hands on learner so I need examples and constant re reading to comprehend :(

but I think I know what you mean so your saying if the chief complaint is Cough I would then look at the Respiratory system criteria and count the bullets there in order to determine if the overall e/m is based on what was done on the exam? did I say that right?

someone should come up with a webinar or training on how to use and understand the 95/97 DG :)
 
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