Wiki Initial Skilled Nursing Facility Visits

[jennyifer]

The doctor I am coding for sees a patient in a skilled nursing facilty for the first time and dictates his note. He has a problem focused HPI, detatiled exam, and low complextity MDM. The initial visits require 3 of 3 components to code the lowest level and the hpi and exam must be detailed or comprehensive.

So, the MD doesn't meet the requirements to code the lowest initial SNF code. I was told by auditors we can use subsequent codes in an inpatient setting if the MD can't meet the documentation requirements. Does this apply to SNF initial visits too?

 

[ajs]

The doctor I am coding for sees a patient in a skilled nursing facilty for the first time and dictates his note. He has a problem focused HPI, detatiled exam, and low complextity MDM. The initial visits require 3 of 3 components to code the lowest level and the hpi and exam must be detailed or comprehensive.

So, the MD doesn't meet the requirements to code the lowest initial SNF code. I was told by auditors we can use subsequent codes in an inpatient setting if the MD can't meet the documentation requirements. Does this apply to SNF initial visits too?

So what is missing from the history that would potentially make it a detailed history? Are there details that were perhaps discussed and left out of the providers dictation? I would definitely review the documentation with the provider...an addendum could be added if details were missed. If there are not more details, then educating the provider about what is needed on the Initial SNF visit would be good. And in that case you would just code a subsequent visit that meets the documentation provided.