Sarah Ann
Networker
It could be me.
One of the questions I have is regarding conditions that we can always code in the absence of provider documentation-- what?
Here's an example of one of the modules-
HPI Mr. Jones presents today for follow up to his recent visit for anginal episodes. We started him on Ranexa and he reports that it's helped. His latest EKG looks good. Pt. had a prior CABG in 05. He is actively working. His COPD acts up with humid weather.. He's been using his rescue inhaler more frequently in the Summer.
Assessment/Plan angina: stable on Ranexa. encouraged him to continue with healthy lifestyle changes.
CAD s/p CABG. repeat nuc. stress test. cont. with beta blocker and statin.
HTN: controlled with lisinopril.
COPD advised to avoid exercising in humid weather.
The documentation supports- angina, CAD,HTN, COPD I get it MEAT/TAMPER I would have coded it that way in real life.
There are several examples that are just like that they demonstrate MEAT.
NOW I'm reading that this isn't necessary with certain conditions like CAD.
I don't understand why they give examples like the one above, and then a few chapters later according to CMS RAPS you can code those dx's without MEAT? WHAT??
Then I'm reading all dx's must be documented in the face to face encounters. A problem list alone will not support the dx's reported.
So what if I FIND CHF, CAD Etc . on the problem list are they saying in essence they CAN be coded in the absence of supporting documentation? I'm confused because I thought we NEEDED the documentation during the encounter, with MEAT and or TAMPER for the conditions to be coded.
I guess I'm confused.
If anyone can clear up this confusion it would be helpful. I just think I'm seeing conflicting information.
Thanks!
One of the questions I have is regarding conditions that we can always code in the absence of provider documentation-- what?
Here's an example of one of the modules-
HPI Mr. Jones presents today for follow up to his recent visit for anginal episodes. We started him on Ranexa and he reports that it's helped. His latest EKG looks good. Pt. had a prior CABG in 05. He is actively working. His COPD acts up with humid weather.. He's been using his rescue inhaler more frequently in the Summer.
Assessment/Plan angina: stable on Ranexa. encouraged him to continue with healthy lifestyle changes.
CAD s/p CABG. repeat nuc. stress test. cont. with beta blocker and statin.
HTN: controlled with lisinopril.
COPD advised to avoid exercising in humid weather.
The documentation supports- angina, CAD,HTN, COPD I get it MEAT/TAMPER I would have coded it that way in real life.
There are several examples that are just like that they demonstrate MEAT.
NOW I'm reading that this isn't necessary with certain conditions like CAD.
I don't understand why they give examples like the one above, and then a few chapters later according to CMS RAPS you can code those dx's without MEAT? WHAT??
Then I'm reading all dx's must be documented in the face to face encounters. A problem list alone will not support the dx's reported.
So what if I FIND CHF, CAD Etc . on the problem list are they saying in essence they CAN be coded in the absence of supporting documentation? I'm confused because I thought we NEEDED the documentation during the encounter, with MEAT and or TAMPER for the conditions to be coded.
I guess I'm confused.
If anyone can clear up this confusion it would be helpful. I just think I'm seeing conflicting information.
Thanks!
