Wiki Documentation

[amylynne69]

If you are looking at documentation for a chart that is not on a Medicare patient, and the guidelines for the insurance company in question do not mention 1995 or 1997 guidelines, is there more room for interpretation of documentation guidelines, or do 1995 and 1997 guidelines apply to all documentation for CPT regardless of the insurance company? Thanks!

 

[mitchellde]

It applies to all payers. I have never heard of any other acceptable method for assignment of the level. The three key components are not a Medicare issue they are written in the CPT system as well as the documentation guidelines.

 

[amylynne69]

Ros

Thank you. This provider is stating though, that his ROS is complete because they have a list of symptoms in the chart, and they have circled any that are positive. They contend that the other symptoms are negative and reviewed simply because that policy is understood in their office. There is not a note anywhere about negative systems. So I think my question is more about the documentation guidelines. If the insurance company doesn't state that they have to use 1995 and 1997 guidelines, can they use their own guidelines to come up with a complete ROS? They keep saying that those guidelines do not apply for this insurance company. Only for medicare

 

[mitchellde]

No you cannot use your own guidelines. and this is a chart note that must stand on its own if it is ever reviewed by an outside source. Having something understood in the office will not suffice as information for independent review. This is why we have documentation guidelines for what must be included in the note to be considered for a particular level of care. See the 95/97 guidelines are not visit level guidelines, they are documentation guidelines. If it is not in the note, it cannot be considered as information for that visit.

 

[amylynne69]

thank you.