cadillacmtn
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My understanding is that when billing on time, and >50% of a visit was dominated by counseling/coordination of care, the key components of HPI, exam, MDM do not have to be met. Our medical director has come up with a form used for palliative care consults where the hospital attending has requested our providers come in and do an inpt goals of care consult: pt has life-limiting illness and major decisions must be made regarding treatment vs quality of life, etc. Lengthy discussions take place with pt/family re disease progression, EOL decisions, treatment options, and provider must educate pt/family about realities of prognosis, etc.
So.... this form is tailored so provider can give summary of what was discussed, who was present, who is making medical decisions. There is also a place for pt vitals, review of labs, and the F2F time in patient room, along with floor time, doc time. However, there is no exam documented, and no hpi other than assessment of terminal/comorbid conditions. Are we ok on this, or do we still have to have completely documented the exam HPI in addition?
The guidance from CMS is pretty limited, other than that the level is based on time spent, and required documentation of F2F, total inpt time, summary of discussion, and stmt re: >50%........ There are countless reputable websites devoted to EM that indicate (or interpret) that the key components used to code on complexity are not required when billing on time.
Please advise!
So.... this form is tailored so provider can give summary of what was discussed, who was present, who is making medical decisions. There is also a place for pt vitals, review of labs, and the F2F time in patient room, along with floor time, doc time. However, there is no exam documented, and no hpi other than assessment of terminal/comorbid conditions. Are we ok on this, or do we still have to have completely documented the exam HPI in addition?
The guidance from CMS is pretty limited, other than that the level is based on time spent, and required documentation of F2F, total inpt time, summary of discussion, and stmt re: >50%........ There are countless reputable websites devoted to EM that indicate (or interpret) that the key components used to code on complexity are not required when billing on time.
Please advise!