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lharding512

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My physician wants to have a separate questionnaire that the patient fills out explaining the reason for the visit for ICD-10 (as well as for PQRS, which we are not currently reporting) rather than having to document that information himself.
I do not feel that part of the chart is the same as part of the exam. He does not agree, because as he puts it there are several different pages in EMR (which we are also currently not using), so it is not different that having several different pages in a paper chart.
Opinions?
 
Look at CMS' 1995 and 1997 documentation guidelines. Certain parts of the record may be documented only by the provider. ROS may be documented on a form by the patient, but must be verified by the provider. PFSH as well.

History, exam, assessment and plan are all required to be documented by the physician.

Forms can be used as part of the medical record (such as the ROS form above), however coding may be abstracted only from medical records that are authenticated by a physician or NPP.
 
Thanks. That is what I thought too, now to convince him. I am fine with what the 95 and 97 guidelines say, but not with the patient doing all the history. He doesn't see it any different than a doctor signing off on a residents note. I see a huge difference.
 
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