Wiki Physician Documentation

[BNB0810]

I have a physician in our practice that regularly fails to document follow up or existing problem. For example ( 12-year-old boy complains of 2/10 sore throat x2 days, intermittent, exacerbated by swallowing, nonradiating. The patient says he feels better today compared to yesterday) this patient had a visit 15 days before this one. This would code to a higher level, but if they would document follow up it could code to middle or lower level.

I told my director that the document must include status of the presenting problem (follow up, or worsening) but she wants me to find supporting evidence to show the physician proof that they need to let the coder know the status of the presenting problem.

I don't know where to even begin to look for this. Does anyone have any websites so I can find documentation requirements on this issue. It is greatly appreciated.

Thanks
I hope I made sense.

 

[Chelle-Lynn]

Most offices will adopt Medicare guidelines and requirements in regards to these situations. In the attached link CMS reviews the documentation needed for E&M's. It specifically discusses the need for relevant history as well as the patient's progress in regards to the care they have received. This would help support your request for worsening, improving, no change, etc.


https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf

 

[BNB0810]

Thanks so much! Will read this this weekend.