Wiki Documenting Return to Office requirement

[upuranik]

I am working with a group that is currently under a Pre-Payment Review with Anthem and we are having to send supporting documentation with every claim. As I am reviewing their E/M notes in the EHR I am finding that the Return to Office field is typically blank, yet up in the A/P the doctor typically dictates when and what the patient is to return for. In my previous experience with other practices that used dictation, they still documented the Return to Office field. Is this required, or will it pass since it is stated in the A/P?

Thanks in advance!
Gina

 

[csperoni]

Regardless of what heading it is documented under, you do get credit for the information being there. It's obviously a better practice to have the relevant information under the correct headings. Just like if HPI elements are documented under the MDM section, you can count it as HPI (you just can't count it twice).
Having the items under the appropriate headings does make it easier for your coders and helps justify coding if audited since it is 100% clear.

 

[upuranik]

Regardless of what heading it is documented under, you do get credit for the information being there. It's obviously a better practice to have the relevant information under the correct headings. Just like if HPI elements are documented under the MDM section, you can count it as HPI (you just can't count it twice).
Having the items under the appropriate headings does make it easier for your coders and helps justify coding if audited since it is 100% clear.

Thank you!