Q: Can a patient checklist be used to contribute to the ROS/PFSH for a visit?
A: Yes, anyone can document the ROS and PFSH. A provider may use the ROS/PFSH from a patient checklist or other means of obtaining the information. The information (ROS/PFSH only) must either be signed or dated by the provider or the provider must reference the date of the checklist in his/her own documentation. Note, when referring back to a previous ROS/PFSH information, it should be a reasonable date to still be considered current (within one year).
Q: Can’t I just sign the resident’s note in order to bill for my services as a teaching physician?
A: No, per the Medicare teaching physician guidelines in order to adequately document a teaching physician’s presence/participation in the service to the patient when there is resident involvement, a provider must document that he/she saw and examined the patient, make reference to the resident’s note, as well as note any agreement/disagreement with the resident’s note and sign and date the documentation.
Q: When a new patient is seen as an inpatient with a practice, when they are seen at the clinic for the first time isn’t that patient still considered a new patient visit?
A: No, a new patient is one has not seen a provider or another provider of the same group practice within the past three (3) years regardless of where the initial patient encounter took place.
Q: What is meant by the term “same group practice”?
A: We define the term “same group practice” to mean all the providers under the same tax identification number.
Q: When a medical student is involved in documenting, what documentation, if any does the teaching physician need to contribute?
A: Per the Medicare teaching physician guidelines, a medical student’s documentation is not equivalent to a resident’s documentation. Any information provided in the medical record by a medical student (other than the ROS/PFSH, which still must be referenced by the provider) must be re-performed and re-documented by the teaching physician. However, if a medical student is merely acting as a “scribe” for the teaching physician, there must be documentation in the medical record to reflect that.
Q: As long as a provider and his/her secretary can read the documentation, that’s good enough?
A: No, Although a provider and his/her secretary may be able to read the documentation, it is a continuity of care as well as a documentation issue. When reviewing documentation to assess the level of service, information that is difficult to read or illegible cannot be used to contribute to the level of service. This can result in a lower level of service or no level of service (depending on the category of the service).
Q: “Our practice can’t afford to buy new coding books every year. The codes don’t change that much anyway.”
A: The coding resources must be updated annually. There are CPT and ICD-9 coding additions, deletions and changes on a yearly basis.
Q: If the diagnosis is documented in the chart, it doesn’t have to be documented each day.
A: Not true. Each encounter should stand alone including the reason for the encounter (diagnosis).
Q: Rule out/questionable diagnosis codes are not “allowed” in the outpatient setting.
A: Rule out, possible, probably and questionable diagnoses are not to be coded in the outpatient setting.
Q: Any patient that is referred to a practice from another provider should be billed as a “consultation”.
A: Not necessarily. In order to bill for a consultation, there must be a request from a provider (or other appropriate source) for opinion or advice, rendering of the service to the patient as well as a report back to the requesting provider. If the intent of the requesting physician is to turn over the care of that patient’s condition to another provider, that would be a new patient visit rather than a consultation.
Can you show me an example of how the desk audit process works?
See this flow chart
.
Can you show me an example of how the desk audit process works?
See this flow chart.
Last Modified:
September 19, 2005
Copyright 2005, Indiana
University Board of Trustees
Privacy Statement - Medical
Disclaimer