Wiki ROS...again

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KMayercsik

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Our doctors are using templates for our new EMR system. One of the blurbs in the ROS section is "As above in the HPI, Otherwise all others as documented in the EMR on 1/1/12 (DOS)."
The nurse documents the ROS and upon review the only problems the patient complained about were constipation and an UTI; and they always review at least 8 systems. The doctor does refer to urinary and bowel problems in the EMRs HPI. The PE and MDM supports a level 99213, and a level three was billed. But this automatic populated blurb has me concerned.
Any thoughts?
 
I would be concerned as well. Doctors/coders become comfortable, because EMRs allow documentation captured to be deemed "safe." But September of this year, the U.S. Department of Health and Human Services, and the Attorney General U.S. Department of Justice made it clear that these kinds of documentation will be diligently reviewed and prosecuted to the fullest extent of the law. The letter refered to this as “reviewing billing through audits” and “initiating more extensive medical reviews to ensure that providers are coding evaluation and management services accurately.”
 
@ hewitt, would you by chance have the link for the audit/medical review information from the U.S. Department of Health and Human Services, and the Attorney General U.S. Department of Justice?
 
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