As many of you know, the Compliance Department routinely audits charts from throughout YMG. Based on recent experience, here are some common issues that come up:
- When bringing forward the History of Present Illness from a prior visit, please remember to update the information with data relevant to today’s visit.
- Physicians must add a complete note describing in detail the services provided to a patient when working collaboratively with an APRN or PA.
- Physicians must append the modifier GC to the charge when working collaboratively with a GME resident or fellow.
- Physicians must include a personalized statement when working with a GME resident that supports that they saw and evaluated the patient, and that describes their role in the plan. The note must be personalized for each patient. It’s okay to start from a template, but the note has to be personalized to the patient.
- If billing E&Ms by time, the provider must document the time spent counseling and coordinating care, and the total time of the visit. The only time that can be counted is the billing practitioner’s face-to-face time with the patient.
- Do not copy or forward documentation from another practitioner’s note without proper attribution.
- Please bill using medically relevant diagnosis codes for your services as well as for orders for diagnostic testing.
- Bill using the actual date of service if you are documenting your note the next day. The date of service can be noted in Epic even for notes written later.
- Remember to include the time in your note for such time-based codes as critical care and hospital discharge codes.
- Document the critical care intervention when billing critical care.
- Individuals not employed or leased by YMG can document the patient’s vitals; review of systems; and past, family, and social history. It must be evident that the MD reviewed these components to consider them in the level of E&M to bill.
Submitted by Deborah Lyman on May 15, 2015