nc_coder
Expert
I am responsible for auditing Hospice and Palliative care services. This is completely new to me. I am having a very hard time finding guidelines and regulations for these services. Does anyone know of a really good source to find auditing tips for this? My biggest issue is HPI elements when the encounter is for Goals of Care. The particular case I am working on now is a patient that cognitively does not have decision making capacity. The provider did document that greater than 50% of the 50 minute visit was counseling and coordination of care. The majority of this time was spent on the phone with the HCPOA. There really aren't many elements in HPI. There was a comprehensive exam. I just need some guidance on auditing the documentation for these services.