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Archive for the ‘Billing’ Category

Charting Deficiencies

i had a meeting with beth & jill this morning to review our charting deficiencies as a practice. though there are some outliers, it seems that A LOT of our deficiencies can be attributed to holes in the documentation of review of systems & past social/family history sections.

several pearls/caveats …

· in psychiatric ROS, even though etoh abuse is listed there, it does not technically count as a psychiatric review. the coders will put that into the social history bucket.

· documented allergies can count as either part of the past medical history OR the review of systems …. as long as you click the boxes “nursing records reviewed” & “agree with nursing records” you get credit for it.

· for medical student charts, the coders can only use the PMH & ROS sections from their chart. you MUST reproduce the HPI & PE to get credit for it.

· and always remember the 5/10/20 rule … 5 elements in HPI, 10 in ROS, and 20 in PE. in addition, you must chart in any 2 of 3 sections of past medical history: medical/surgical history, social history or family history.

· please remember to chart for critical care time if appropriate. remember, what the insurance company defines as “critical care” is not necessarily what we consider to be “critical”. it must meet 2 requirements: 1) clinical condition – the probability of imminent or life threatening deterioration in that case and 2) treatment – the failure to deliver treatment or withdraw it would cause clinical deterioration. so for example, you could bill critical care on a rapid a fib patient – because 1) they could deteriorate if you didn’t attend to them & 2) if you didn’t give the appropriate agent to slow down their heart rate, they could develop cardiac ischemia or hypotension.

i will be meeting with some of you individually to go over charts & see if we can determine where the deficiencies specifically lie. i will try to do the top 2 (or should i say bottom 2) on a monthly basis.

as always, feel free to find me to discuss any questions or problems.


Written by reuben

October 7th, 2010 at 11:22 pm

Posted in Billing