Wiki using documentation twice

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Jenna000

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Where i work, the hospital says, if the patient has been seen with in the last 30 days, they Dr just needs to fill out and updated cover sheet, stating whether there are or are not changes, and if so what they are, but then can use the rest of the previous office visit to bill off of for a hospital admit.

1. Can they use the office visit to bill off of if they have already submitted and E/m level off of it?
2. Does anyone have any documentation supporting if this is incorrect or correct.

thanks,
jenna
 
The question is a little confusing to decipher, so my answer many not be perfectly correct.

A surgeon can use an office visit dictation if performed within 30 days of the surgery for an H&P. But they are not billing for an Initial Admit CPT code.

An admitting physician billing an Initial Admit CPT code can only use documentation originating on the DOS as it can only support 1 E&M code. Previous documentation used to bill a DOS previously would not be appropriate.
 
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this is a very confusing question. I am not sure what is meant by very shortly after either. I do know that it is stated in either the Medicare guidelines or the E&M guidelines that each note must be a stand alone note for that encounter and the only information that may be brought forward from a previous encounter is the hstory ROS since that is history, and the provider must documente that is has been reviewed with the patient and nothing has changed. Exam, HPI, and MDM may not be pulled over from a previous visit. I would think that would very close to "cloning" which CMS does have a recent transmittal out regarding this activity and that it is not to be done.
From an ethical standpoint a provider cannot examine a patient a day, a week, a month ago and use that documentation for an encounter today regardless of whether an E&M was originally billed or not since life is never that static, a patient's health status can change, sometimes dramatically from one day to the next.
 
mitchellde said:
this is a very confusing question. I am not sure what is meant by very shortly after either. I do know that it is stated in either the Medicare guidelines or the E&M guidelines that each note must be a stand alone note for that encounter and the only information that may be brought forward from a previous encounter is the hstory ROS since that is history, and the provider must documente that is has been reviewed with the patient and nothing has changed. Exam, HPI, and MDM may not be pulled over from a previous visit. I would think that would very close to "cloning" which CMS does have a recent transmittal out regarding this activity and that it is not to be done.
From an ethical standpoint a provider cannot examine a patient a day, a week, a month ago and use that documentation for an encounter today regardless of whether an E&M was originally billed or not since life is never that static, a patient's health status can change, sometimes dramatically from one day to the next.
Click to expand...

Well stated, Debra~
 
thanks for the replies. sorry it was worded confusingly, but i think you all understood, and i agree, i just wanted opinions on wht i was thinking. To kind of clarify. the hospital has a face sheet, that the dr can mark status unchanged, or status changed and then there is a section to up date the hpi, pfsh, exam and impression and plan. Some of the drs were trying to bill with out completing all the info, or by saying refer to note on this day, which i was trying to explain was incorrect.

Can anyone give me a transmittal number with that information it?

thanks
 
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