June Allen
Member
I have a multitude of questions and I hope you can reply to them
1. Consults: I was trainied that the opinion letter should not have the word "referral" or "referring" as they can imply transfer of care. That said, on or electronic progress notes I see the "Referring Physician" heading all the time. Does that policy still apply and as an auditor do I need to recommed that that heading be changed?
2. Exam: Abdomen vs. GI - where do you place "soft non-tender". I was trained that should be the BA but, others I am find out place that in GI which I place elements like "no bowel sounds" or "organomegaly" etc.
I was trained “cyanosis” = Skin, “clubbing” = MS and “edema” = CV. Is that correct?
3. ROS: I am finding that providers are using the single word "negative" for the systems. I have been told that is ok but, if they give me 10 systems with "negative" and 1 or 2 pertinent positives what cam I crediting the "negative" systems to? Do I presume that if a pt arrives with a abd pain that "negative" in neuro, ent, cardio means that provider/ancillary staff asked pt and there is nothing worng? Can you forward me any guidelines on this subject, please.
4. CC/HPI: EHR document, CC heading has "follow up for MRI". We know that the information in this heading/field imports from the appointment file. So, if the provider does not change the field it we do not conside it a "clear & concise" statement from the patient. So we then look for the provider to restate/validate the CC in HPI. HPI...provider's only statement "no come w/rt lower extremity pain and muscle tightness he is now coming to f/u on his results" I have been told that that entire statement should be considerd as CC with no credit to HPI; as it would be double dipping. Do you agree?
5. Double dipping: I understand what is consider "double dipping" " started yesterday" cannot be considered timing and duration but, can you take elements from CC to support HPI?
6. Incident-To: what does an auditor need to check you?
7. Pre-Operative/Medical Clearance: I have seen articles that a consult can (est/new pt) can submit a consult (following guidelines) for the medical clearance.
a. Is this for all specialties or just for PCP(pediatricians/internist/family doctor) and/or cardiologist?
b. Are you aware of a specific CMS guideline/policy?
c. Within the Table of Risk, do you then credit the condition(s) requiring the surgery within presenting problems & v72.8x(primary)?
d. What then do you credit for the Management Options? Ex: v72.83 for child with hernia
8. Preventive Medicine: Having a difficult time determining the comprehensive history for child and adult. The way I see it the comp hx should have past illness, surgeries, meds, allergies, birth, family & social hx, status chronic conditions. But, I ma finding providers are documenting develomental (child) status as history. Is that correct/acceptable? Do you have a guidlance or guidelines that I can use, please?
9. HCC Coding:
a. if the provider documents meds that relate to chronic conditions but, the patient is be for the flu, prescribed OTC that will not interact with current meds (not stated but implied) and did not treat any of the active meds related conditions, do you still document code for the HCC (DM, HTN, etc) or the related meds rxHCC?
b. If the pt has a BKN and is a diabetic whoch HCC code is placed first or does it not matter?
c. What is the best book for HCC training/reference?
Thank you and I enjoy your webinars
1. Consults: I was trainied that the opinion letter should not have the word "referral" or "referring" as they can imply transfer of care. That said, on or electronic progress notes I see the "Referring Physician" heading all the time. Does that policy still apply and as an auditor do I need to recommed that that heading be changed?
2. Exam: Abdomen vs. GI - where do you place "soft non-tender". I was trained that should be the BA but, others I am find out place that in GI which I place elements like "no bowel sounds" or "organomegaly" etc.
I was trained “cyanosis” = Skin, “clubbing” = MS and “edema” = CV. Is that correct?
3. ROS: I am finding that providers are using the single word "negative" for the systems. I have been told that is ok but, if they give me 10 systems with "negative" and 1 or 2 pertinent positives what cam I crediting the "negative" systems to? Do I presume that if a pt arrives with a abd pain that "negative" in neuro, ent, cardio means that provider/ancillary staff asked pt and there is nothing worng? Can you forward me any guidelines on this subject, please.
4. CC/HPI: EHR document, CC heading has "follow up for MRI". We know that the information in this heading/field imports from the appointment file. So, if the provider does not change the field it we do not conside it a "clear & concise" statement from the patient. So we then look for the provider to restate/validate the CC in HPI. HPI...provider's only statement "no come w/rt lower extremity pain and muscle tightness he is now coming to f/u on his results" I have been told that that entire statement should be considerd as CC with no credit to HPI; as it would be double dipping. Do you agree?
5. Double dipping: I understand what is consider "double dipping" " started yesterday" cannot be considered timing and duration but, can you take elements from CC to support HPI?
6. Incident-To: what does an auditor need to check you?
7. Pre-Operative/Medical Clearance: I have seen articles that a consult can (est/new pt) can submit a consult (following guidelines) for the medical clearance.
a. Is this for all specialties or just for PCP(pediatricians/internist/family doctor) and/or cardiologist?
b. Are you aware of a specific CMS guideline/policy?
c. Within the Table of Risk, do you then credit the condition(s) requiring the surgery within presenting problems & v72.8x(primary)?
d. What then do you credit for the Management Options? Ex: v72.83 for child with hernia
8. Preventive Medicine: Having a difficult time determining the comprehensive history for child and adult. The way I see it the comp hx should have past illness, surgeries, meds, allergies, birth, family & social hx, status chronic conditions. But, I ma finding providers are documenting develomental (child) status as history. Is that correct/acceptable? Do you have a guidlance or guidelines that I can use, please?
9. HCC Coding:
a. if the provider documents meds that relate to chronic conditions but, the patient is be for the flu, prescribed OTC that will not interact with current meds (not stated but implied) and did not treat any of the active meds related conditions, do you still document code for the HCC (DM, HTN, etc) or the related meds rxHCC?
b. If the pt has a BKN and is a diabetic whoch HCC code is placed first or does it not matter?
c. What is the best book for HCC training/reference?
Thank you and I enjoy your webinars