Wiki Documentation Insurance/Cosmetic

[apoland]

Hello,

Our practice treats a variety of patients including cosmetic, worker's comp, medicare, commerical insurance, etc. We have always been advised that the providers do not need to document seperate procedure/office notes when a patient is being treated for an insurance and cosmetic issue. The non-insurance info can be blacked out from the note if requested to support the insurance services. The American Society of Plastic Surgeons has advised that we don't need to seperate the notes just be very clear on what is cosmetic and what is not. From a compliance standpoint is this accurate? Is there guidance somewhere on this?

I appreciate any and all help.
Thank you,

Autumn

 

[csperoni]

You should get official compliance or legal advice on this. However, I will weigh in with my opinion.
It is typically not "required" to have separate notes. Doing so does make a gray area much more black and white.
Let's use an example of a worker's comp patient presents for hitting his thumb with a hammer at work 2 hours earlier. While provider is evaluating thumb, patient mentions BPs at home have been elevated, despite taking meds as prescribed. Provider reviews home BP records and recommends increasing medication dose and returning in 2 weeks for a re-evaluation.
If that is all part of one note, it makes leveling each visit very complicated. It also creates a potential HIPAA violation if either WC or commercial payor requests documentation. Someone has to realize there is mixed information at block it out. It also looks very suspicious to either carrier if you submit documentation with redacted information.
I would STRONGLY recommend 2 separate notes.

 

[apoland]

You should get official compliance or legal advice on this. However, I will weigh in with my opinion.
It is typically not "required" to have separate notes. Doing so does make a gray area much more black and white.
Let's use an example of a worker's comp patient presents for hitting his thumb with a hammer at work 2 hours earlier. While provider is evaluating thumb, patient mentions BPs at home have been elevated, despite taking meds as prescribed. Provider reviews home BP records and recommends increasing medication dose and returning in 2 weeks for a re-evaluation.
If that is all part of one note, it makes leveling each visit very complicated. It also creates a potential HIPAA violation if either WC or commercial payor requests documentation. Someone has to realize there is mixed information at block it out. It also looks very suspicious to either carrier if you submit documentation with redacted information.
I would STRONGLY recommend 2 separate notes.

Thank you, I appreciate your reply. I will have a more detailed conversation with management about reviewing our process.