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VEIN PROVIDERS –WHAT YOU MAY NOT KNOW ABOUT E/M DOCUMENTATIONLast Updated: 8/11/2012
VEIN PROVIDERS –WHAT YOU MAY NOT KNOW ABOUT E/M DOCUMENTATION
One of the advantages of utilizing an EMR to document E/M services is that it allows you to easily incorporate legible vital information into the patient’s record. But due to the ease of entering information into the record, there is a risk of having a false-sense of security in thinking that with all this information, certainly the documentation requirements have been met. To help safe-guard your records in the event of an audit and to streamline your documentation, it is imperative that you have a clear understanding of what is required. This article was written to familiarize you with commonly misunderstood areas and to provide you with quick and easy-to-follow solutions.
ARE YOU USING A SCRIBE?
Using a scribe is permitted but there are rules that have to be followed. Medicare defines a scribe as a "living recorder,” documenting in real time the actions and words of the provider as they are done. If this is done any other way, it is inappropriate. If using a scribe, the following statement or one similar has to be included in the patient’s medical record and both the scribe and provider need to sign the notes:
Scribe: "Written by ________, acting as scribe for Dr. _________ .
Provider: "This note accurately reflects the work and decisions made by me, Dr. ___________.”
CAN CERTAIN COMPONENTS OF THE E/M BE UPDATED BY MY MEDICAL STAFF?
Yes, E/M services are comprised of three key components: history, exam, and medical decision making. For the history component, other medical staff can document the Past Medical or Family/Social History section, the Review of Systems (ROS), or both. But in order to use this information to determine the level of E/M service, you must document that you reviewed and addressed the information obtained.
IS YOUR CHIEF COMPLAINT "FOLLOW-UP” WITHOUT IDENTIFYING THE PROBLEM(S)?
Do not limit the chief complaint to "follow-up” without identifying the problem(s) being followed.
Not acceptable: Clinical Indications: Follow-up
Acceptable: Clinical Indications: Follow-up chronic venous insufficiency with edema of the right lower extremity
DOES MEDICAL NECESSITY DETERMINE YOUR LEVEL OF SERVICE?
Just like the vein treatments you perform, E/M services must also be medically necessary. But unlike treatments that have a defined list of payable diagnosis codes, E/M services do not. A defined list does not exist because E/M services cover a wide-range of specialties. The "burden of proof’ has to be found in your documentation.
Recommendation: Incorporate in your documentation the clinical indications that made you modify or contribute to the patient’s current visit.
Caution: Do not record unnecessary information solely to meet requirements of a high-level service when the nature of the visit dictates a low-level service is medically appropriate.
Keep in mind that in order to meet requirements of a high-level service when the nature of the visit dictates a low-level service to have been medically appropriate.
CREATING AND THE MEDICAL RECORD – WHY IS IT THE PROVIDER’S RESPONSIBILITY?
With the implementation of the EMR, it has become very easy for an authorized individual such as a scribe to write notes in the medical record on your behalf. Keep in mind that it is not enough to follow behind and sign the note. It is imperative that you review it to make sure it is an accurate reflection of what you did and why you did it. Documentation that has not been substantiated by you is an obvious risk to the patient’s health. In addition, it can lead to coding and billing errors which could also trigger an audit. Keep in mind that reimbursement for services and procedures you perform is based on Relative Value Units (RVUs). The value of the RVU reflects the time spent prior to a service, performing the service, and time spent following the service, which includes charting. In other words, you get paid to document the service/procedure you performed.
Take the time to find out what the documentation requirements are for E/M services. Often, simply by including a certain statement or even just a specific word is all it takes to make your documentation compliant and/or billable. Medicare pays for medically necessary and reasonable services, and expects the person receiving payment to be the one responsible for delivering the services as well as creating the record. Before signing, review the record to ensure the documentation accurately depicts the service you performed because in the end, you are responsible for the record and the codes submitted.
This is also available in our Vein Journal Flipbooks!
Wendy Block, CPC, RCC, CIRCC
Sr. Coding Advisor
3333 S. Arlington Road | Akron, Ohio 44312
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