How To Check For A Medical Bill Of Health In Texas

Transcription

1 Billing Cmpliance Prgram Billing Mnitring Handbk (Used and mdified with permissin f Creightn University, 2007) Initial Publicatin: February 22, 2007 Revised: January 1, 2008 March 1, 2009 January 1, 2010 January 1, 2011 January 1, 2012 January 1, 2013 January 1, 2014 January 1, 2015 Institutinal Cmpliance Officer Snya Castr (806) Cmpliance Directr Jhn Geist (806) Reginal Billing Cmpliance Officers: AMARILLO: Teri Murphy, CPC, CMOM, CMIS, CMC, CPC-I (806) EL PASO: Gail Hayden, BSBA, CCS-P (915) LUBBOCK: Crlis Nrman, MAM, RHIT, CCS-P, CCS (806) PERMIAN BASIN: Vacant (806)

2 T Reprt Fraud, Waste, r Abuse at TTUHSC, Cntact: Yur Supervisr Institutinal Cmpliance Officer: Cmpliance Directr: Office f Audit Services: State Auditr s Office: TX-AUDIT ( ) EthicsPint: (Als available in Spanish) Billing Mnitring Handbk ii Revised

3 Billing Mnitring Handbk Table f Cntents MONITORING PROCESS 1 Selecting the Mnitring Items 1 A. General Instructins - MDaudit 1 B. Prvider Mnitring Reprt Audit Package 25 C. Mnitring Evaluatin and Management (E/M) Services, In Office Prcedures, and Diagnstic Services General Principles (CMS' 1995 and 1997 E/M Dcumentatin Guidelines) E/M and/r In-ffice Prcedures and Diagnstic Tests Wrksheet As applicable and used as a reference fr manual auditing Teaching Physician Rules Review Level f E/M Services Only Appendix C-1 (and E, if Applicable) Sectin 3; Part A Number f Diagnses r Management Optins Sectin 3, Part B: Risk f Cmplicatins and/r Mrbidity r Mrtality Sectin 3, Part C: Data Reviewed r Ordered Sectin 3, Part D: Final Results Table f Cmplexity fr MDM Level Mnitring Guidance fr MDM Manual Instructins E/M Cding Tables 45 D. Ophthalmlgy and In-Office Prcedures and Diagnstic Services -Appendix C Prcedures that may be included as part f general phthalmlgic services and may nt be reprted separately nr billed are: Initiatin f diagnstic and treatment prgrams include: 46 E. Preventive Services/Annual Exams/Texas Well-Child Visits Medicare Initial Preventive Physician Exam (G0402-G0405) Medicare Female Pelvic/Breast/Pap (G0101): Cmplete 1997 Dcumentatin Guidelines fr Geniturinary Texas Health Steps (THSteps) Well Child Check-up (Medicaid) - Appendix D Medicare Annual Wellness Visit (G0438-G0439) 47 F. Nn-Physician Prvider Issues Medicare Incident T Rules Shared/Split E/M Services 48 G. Operatins/Prcedures/OB Deliveries Mnitring Tl Appendix F 49 H. Psychiatric (Excluding E/M Services) Mnitring Tl Appendix G 49 I. Screening Diagnstic Radilgy and Anatmical Pathlgy Services Mnitring Tl Appendix H 49 Billing Mnitring Handbk iii Revised

4 J. Anesthesilgy Services Mnitring Tl Appendix I Persnally Perfrmed Medically Directed Medically Supervised Mnitred Anesthesia Care 50 K. Medicaid Genetics Services Mnitring Tl Appendix J 50 AUDITING THE ICD-9 CODE 51 A. General Principles 51 B. ICD-9 Mnitring Prcess Manual Instructins Identify and transfer the ICD-9 cdes Refer t the medical recrd and identify each diagnsis, cnditin, r ther reasn fr the encunter Lk up cde in Vlume II and crss reference in Vlume I f ICD If an encunter requires an E-cde(s) t reprt an external cause f injury r a pisning 52 C. Medicare Advance Beneficiary Ntice (ABN) Requirements 52 OTHER MONITORING TIPS 54 A. Critical Care - Reference: IOM , Chapter 12, Sectin B. Mdifier C. Mdifier D. Cnsultatin Requirements Cnsultatin Request: Render an Opinin: Written Reprt t the Requesting Physician: Transfer f Care Initial Cnsultatin Services Cnsultatin fr Preperative Clearance 55 E. New Patient vs. Established Patient New Patient Established Patient 56 F. Preventive Care, Immunizatins, Screening Pelvic 56 Billing Mnitring Handbk iv Revised

5 Appendices Table f Cntents Appendix C-1: E/M and/r In-Office Prcedures and Diagnstic Services Appendix C-2: Ophthalmlgy Services Mnitring Tl Appendix D-1: Medicare Initial Preventive Physical Exam Mnitring Tl Appendix D-2: Texas Health Steps Well Child Check-Up Appendix D-3: Medicare Annual Wellness Visit Mnitring Tl Appendix E: General Multi-Purpse Examinatin Appendix E: Cardivascular Appendix E: Eye Appendix E: Geniturinary Appendix E: Hematlgic/Lymphatic/Immunlgic Appendix E: Musculskeletal Appendix E: Neurlgical Appendix E: Psychiatric Appendix E: Respiratry Appendix E: Skin Appendix F: Operatins/Prcedures/OB Deliveries Mnitring Tl Appendix G: Psychiatry (Excluding E/M Services) Mnitring Tl Appendix H: Radilgy/Pathlgy Services Mnitring Tl Appendix I: Anesthesilgy Services Mnitring Tl Appendix J: Medicaid Genetics Services Mnitring Tl Appendix K: Examples f Minimally Acceptable Teaching Physician Dcumentatin Fr E/M Services Only Appendix K: Examples f Unacceptable Teaching Physician Dcumentatin Appendix L: Teaching Physician s Electrnic Medical Recrd Macrs Only Appendix M: Audit Scre Methdlgy Billing Mnitring Handbk v Revised

6 MONITORING PROCESS Purpse Findings are reprted frm MDaudit, which prvides the necessary infrmatin t identify and track billing errrs. The infrmatin is autmatically dwnladed int a central database t track and identify risk areas. MDaudit autmatically stres results fr a perid f 10 years. Selecting the Mnitring Items The Billing Cmpliance Office at each campus uses MDaudit sftware, which selects cases (encunters/invices) based n pre-determined criteria (e.g., high level E/M s, tp CPT cdes fr specialty). Ten (10) cases fr each prvider are mnitred during the calendar quarter in accrdance with established plicies and prcedures. Schl f Nursing and Schl f Allied Health prviders will have five (5) cases t be mnitred. The type f cases selected shall represent the types f services rendered by the prvider and be reflective f risks fr that department and/r prvider. The selectin shall include the prvider s name, patient infrmatin and service cdes fr each encunter t be mnitred. On a quarterly basis, the Billing Cmpliance Office will send an t the department s lead/supervising cder infrming them when the audit selectins are available fr review in MDaudit. In rder t cnduct the mnitring, the medical recrd (clinic and/r hspital) must be btained and/r reviewed frm the EHR/EMR used n the campus. Fr surgical prcedures (including OB delivery) it may be necessary t review the surgery schedule fr the dates being reviewed t verify whether there were tw r mre cncurrent surgeries, which wuld impact hw the encunter is audited. If necessary, btain a cpy f the prvider s calendar fr the perid f time under review/audit. This may be necessary fr Primary Care Exceptin Clinics under the Teaching Physician Rule, surgical prcedures, psychtherapy services, etc. The CPT, HCPCS and ICD-9 bks in effect during the time perid under review shuld be accessible. A. General Instructins - MDaudit Enter yur e-raider username and passwrd. (Yu must be entered int the system by yur Cmpliance Office prir t entering the system) NOTE: Yur username will set as default t yur e-raider. And MDaudit is prgrammed t request yur PIN at different intervals thrughut the mnitring/auditing prcess. Billing Mnitring Handbk 1 Revised

7 Chse Audit Management. Audit perid, the prgram shuld default t the current quarter. Click search. Billing Mnitring Handbk 2 Revised

8 Chse the apprpriate practice (department), click magnifying glass by the practice t audit. Click Prvider Audit. Billing Mnitring Handbk 3 Revised

9 Click the magnifying glass by the name f the prvider t audit. Tp Prtin MDaudit: Audit Prvider Detail Screen lists the cases, MRN, Patient Name, Service Date, Svcs, etc. Bttm Prtin f MDaudit: Audit Prvider detail screen (invice) shws the billed/supprted CPT//E/M, Diagnsis, FSC and Scre (e.g., 1:1 = prvider pints: administrative/cder pints. T prceed with mnitring/audit, highlight audit case/encunter in tp prtin f screen; Invice assciated with case/encunter will appear in bttm prtin f screen; Click magnifying glass next t the CPT cde in bttm prtin f screen; Billing Mnitring Handbk 4 Revised

10 This will bring yu t the Prcedure Detail Screen; case number is listed at tp f screen. NOTE: When the case/encunter includes mre than ne CPT/prcedure cde, all CPT cdes must be mnitred/audited including the crrespnding diagnses. The Prcedure Tab f the Prvider Detail screen will be displayed. Yu are able t create a wrksheet via tw different methds: (1) E/M cdes; (2) Other prcedures and/r ther services Methd 1 Creating E/M Wrksheet Click E/M n the Prcedure tab. The E/M buttn is nly displayed fr E/M services. Billing Mnitring Handbk 5 Revised

11 The E/M wrksheet screen is divided int seven different tabs; Service, Histry, Examinatin, Medical Decisin Making, Final Cding, Diagnsis and Findings. Click Histry t begin the mnitring/auditing prcess. Chief Cmplaint is required fr all services. If the prvider is unable t btain, select unbtainable and chse reasn frm drpdwn bx r add reasn. Select HPI, ROS and PFSH elements dcumented. NOTE: Be sure Edit mde has been established (buttn will dim). Billing Mnitring Handbk 6 Revised

12 Click the tab Examinatin. Select the Bdy/Area r Organ System reviewed. Duble click the Bdy Areas/Organ System r right click and select Dcumented r type D next t the element. NOTE: If Perfrmed is chsen, MDaudit will nt calculate apprpriately. The service must be Dcumented. NOTE: T clear an item accidently marked, right click n exam areas/exam elements and select Nt Perfrmed Billing Mnitring Handbk 7 Revised

13 Click the tab Medical Decisin Making: Subcategries appear: Management Optins, Cmplexity f Data and Risk. Click tab fr Diagnstic and Management Optins: Checkmark the apprpriate bx(s) t recrd the elements f diagnstic and management ptins. Billing Mnitring Handbk 8 Revised

14 Click tab fr Amunt and Cmplexity f Data: Checkmark the apprpriate bx(s) t recrd elements f amunt and/r cmplexity f data t be reviewed. Click tab fr Risk f Cmplicatins, Mrbidity r Mrtality: Three additinal tabs appear: Presenting Prblem(s), Diagnstic Prcedure(s) Ordered, and Management Optins. The highest element selected in any categry determines the level f Risk fr the E/M cde. Billing Mnitring Handbk 9 Revised

15 NOTE: If yu clicked Save, yu need t click Edit t be able t cntinue it is nt necessary t save while cmpleting the wrksheet. If the screen needs t be Saved, a message bx will appear. Diagnsis Review: Each CPT cde must have the diagnsis cde reviewed. Click Diagnsis Click tab, Final Cding, t view the utcme f the E/M wrksheet. If yu are ging t use time as a deciding factr, type the minutes n this screen and click the bx fr Apply Time Exceptin. Billing Mnitring Handbk 10 Revised

16 Yu can change supprted categry if necessary, i.e. if billed hspital admit but did nt meet criteria, change supprted categry t Inpatient Care, Subsequent. MDaudit will autmatically calculate accrding t the criteria already entered. When yu feel cmfrtable with the utcme, click Finalize Wrksheet. Billing Mnitring Handbk 11 Revised

17 Once the wrksheet has been finalized, it cannt be changed. The findings can be changed frm the Findings tab, but the wrksheet is final. Yu may click the tab Findings t view the utcme f the wrksheet/cpt cde that MDaudit chse. NOTE: This step can be perfrmed fllwing the diagnsis review. The Supprted CPT cde MDaudit chse may be changed if yu disagree with the result (i.e. PCE Clinic -Dcumentatin meets a but the TP did nt see the patient; therefre, nly is apprpriate.) Click magnifying glass t view Audit Finding Detail screen. Billing Mnitring Handbk 12 Revised

18 If yu change the Supprted CPT cde, be sure 1 is entered fr the units. (Each CPT cde is at least 1 unit.) Right click in the bx t enter pre aut text cmments. Yu may delete anything nt needed and yu may add yur cmments. The cmments will print in the final reprt. Click Save and then click Exit. If yu d nt agree with the wrksheet utcme and it has been finalized, yu can create a new wrksheet. Yu can create as many wrksheets as yu want, but nly a finalized wrksheet will print; and there can nly be ne finalized wrksheet per case/encunter. NOTE: Cmments will nly print if billed CPT and supprted CPT d nt match T Create a New Wrksheet. On Prcedure Detail screen, click Cpy. MDaudit will ask yu if yu want t cpy 1995 r 1997 wrksheet. All the data already entered n first wrksheet will cpy t the new wrksheet. Yu will be able t make any necessary changes n the secnd wrksheet. Finalize the wrksheet yu want MDaudit t remember. See #14 t Finalize Wrksheet. Billing Mnitring Handbk 13 Revised

19 If yu clicked the magnifying glass/ red circle, yu will see the screen belw. Yu may click the green checkmark n this screen if yu agree. If the cde is incrrect, click the red circle. On the Audit Findings Detail screen, type the crrect diagnsis cde n the line fr Supprted Diagnsis cde. Chse the apprpriate finding n this screen. If the pints shuld be applied t the cder, click Administrative. Yu may type cmments n this screen r yu may right click in the bx and insert pre-aut text cmments. Click Save and then click Exit. Billing Mnitring Handbk 14 Revised

20 T add a diagnsis t the claim, be sure yu are n the tab, Diagnsis. Click New Diagnsis lcated at bttm f screen. Type 0dx n the line fr Billed. Tab. Click the red circle. Billing Mnitring Handbk 15 Revised

21 On the fllwing screen, type the supprted diagnsis cde. Tab s MDaudit can enter the descriptin. Select the mst apprpriate finding. Yu may enter cmments in the blank bx r right click and insert pre-aut text cmments. NOTE: Pints have been pre-prgramed in MDaudit. The pints can be edited t be applied t the cder. If s, click Administrative. When finished reviewing the CPT and Diagnsis cde fr each case/encunter, remember t click Cmplete. Billing Mnitring Handbk 16 Revised

22 Methd 2 Used t audit prcedures and/r any ther service, ther than E/M visits. Highlight the case n the tp panel f MDaudit t view yur encunter n the bttm panel. Highlight the next CPT cde n the encunter. Yu may have t click Edit t cntinue. Select the magnifying glass next t the CPT cde. Click the tab, Wrksheet. Billing Mnitring Handbk 17 Revised

23 Click the apprpriate wrksheet type and audit tl. Click Create New Wrksheet. Chices are: Anesthesia Prcedure tab lists several ptins such as, Extended General Prcedure (majr prcedure); General Prcedure (minr prcedures); Genetic; Initial/Cntinuing/Intensive Care (Critical Care); Nenatal/Pediatric (Critical Care); Ophthalmlgy; Psychiatry; Radilgy/Pathlgy; SOAH. OB (Texas Medicaid visits) Preventative (Well visits, THSteps, Well Wman) Regulatry (Incident-t) Answer the questins n the wrksheet. If the answer t the questin is N, yu may have t click NA s the wrksheet des nt create a finding. If there is a finding and the CPT cde needs t be crrected, click N. A message will appear n the right side. Highlight Yes t create a finding. Type the supprted cde and tab. If the CPT cde is crrect, click the green checkmark. Be sure the 1 is in the Units clumn. Finalize Wrksheet. Click Exit. Billing Mnitring Handbk 18 Revised

24 Select Diagnsis tab review diagnsis, then apprve r disapprve; If disagree with billed diagnsis; fllw instructins listed abve in Methd 1 - #21-#29. Click Cmplete when yu are finished evaluating the diagnses. Click Exit until yu arrive at the beginning f the audit. T add a new prcedure r E/M nt billed The first screen, Audit Prvider Detail, lists all the cases/encunters; highlight the case that requires an additinal CPT cde. Click Add Transactin. Yu may need t click Edit t cntinue. Billing Mnitring Handbk 19 Revised

25 Next screen, chse either Prspective r Retrspective n Entry Reasn. TAB TWICE which brings yu t the bttm. If yu did nt tab twice in previus step, re-start. When yu tab twice, MDaudit brings in the invice number fr this case/encunter. Billing Mnitring Handbk 20 Revised

26 Type 0prc under CPT and tab. If yu need t add an E/M cde, type 0em. Tab. Click Save. MDaudit will take yu t the beginning screen f this case/encunter. Click the magnifying glass next t 0 Prc N Prcedure r 0em whichever is applicable Billing Mnitring Handbk 21 Revised

27 Click the red circle. Enter the crrect CPT next t Supprted and tab. Add mdifier as apprpriate and be sure 1 is listed in the Units clumn. Chse the apprpriate Findings. Yu may assign the pints t the cder by clicking Administrative. Yu may enter cmments in the blank bx. Or, yu may right click in the bx. Chse Cmments in the message bx that will appear. Billing Mnitring Handbk 22 Revised

28 Highlight the phrase and yu may click either Insert r Replace. Click the tab, Diagnsis, and either agree with the cde r click the red circle t g t the findings screen. Cntinue with instructins listed in Methd 1, # T add an additinal finding t an E/M and/r ther CPT cde On Prcedure Finding Detail screen r the Audit Finding Detail screen (next slide), yu can add an additinal finding t the CPT cde, i.e. yu agree with the CPT cde but the date f service is wrng r billed prvider is wrng r need a mdifier r there is insufficient teaching physician dcumentatin. Click the magnifying glass next t the CPT cde r diagnsis cde. Billing Mnitring Handbk 23 Revised

29 Once the cde has been reviewed, click Save at bttm f screen. Then yu are able t click New at bttm f screen if yu have an additinal finding t the CPT cde and/r the diagnsis cde. Yu may click Administrative if yu want the pints t g t the cder. Type cmments in the blank bx n this screen. Yu may right click and bring in aut text. Click Save and Exit. Billing Mnitring Handbk 24 Revised

30 B. Prvider Mnitring Reprt Audit Package Purpse After the mnitring prcess has been cmpleted fr that prvider, a designated persn is t share the mnitring results with the prvider and btain the prvider s signature n the signature letter and include the date. The Cder(s) and Mnitr(s) are t sign and date als. A cpy f signature letter is retained by the Department and the riginal is sent t the campus Billing Cmpliance Directr/Officer t be maintained fr (10) ten years. If the prvider and/r cder refuse t sign the signature letter, indicate that refusal n the signature line and submit t the campus Billing Cmpliance Office. It is imprtant that the prvider/department retain a cpy f the signature letter. MDaudit sftware will retain the mnitring results fr ten (10) years. Instructins fllwing each mnitring quarter. The fllwing actin(s) may be necessary. Refunds f any errneus payments; Additinal educatin; Oral/written ntice; Required additinal reviews; and Any ther crrective actin Hw t Print Reprts frm MDaudit Frm the main menu, click the tab, Reprts. Billing Mnitring Handbk 25 Revised

31 The ptin t click Audit Package will appear. Highlight yur department and click the tab, Reprt Selectin. At the bttm f the screen, yu may chse the Audit Perid. Package Type Audit r Prvider. Audit will give yu a summary f the results fr all prviders audited this quarter. Chse whichever reprt yu want t view. Click View. If yu chse the selectin Prvider, see instructins n the next slide. Billing Mnitring Handbk 26 Revised

32 If yu chse Prvider, anther tab appears and yu must click Prvider Selectin. Highlight the prvider yu want t view. G back t the tab Reprt Selectin. Chse the reprt yu want t view/print fr that particular prvider. Billing Mnitring Handbk 27 Revised

33 A snapsht f the signature letter is shwn belw which must be cmpleted fllwing the cmpletin f the audit. The riginal is t be sent t the Cmpliance Office. Frm: Subject: Institutinal Cmpliance Department Mnitring Results Prvider Name (Print) Department: The Office f Inspectr General has prvided guidance t healthcare prviders regarding auditing and mnitring activities and cnsiders mnitring an essential element f an effective cmpliance prgram. In accrdance with OIG guidance and TTUHSC s plicies and prcedures, each clinical Department and/r prvider shall be mnitred annually t verify accuracy f cding, identify ptential r actual billing/cding cmpliance risks, and imprve dcumentatin and cding f health care items and services. Such findings will be dcumented and reviewed with the applicable department r prvider. Yur signature belw prvides verificatin that the mnitring findings have been presented and discussed. THANK YOU fr yur cntinued cmmitment t prper dcumentatin and cding. Prvider: Cder: Mnitr: Date: Date: Date: Ttal Pints Prvider: Ttal Pints Cder/Biller: Ttal Pints Other: Quarter: C. Mnitring Evaluatin and Management (E/M) Services, In Office Prcedures, and Diagnstic Services 1. General Principles (CMS' 1995 and 1997 E/M Dcumentatin Guidelines) MLN/MLNPrducts/Dwnlads/eval_mgmt_serv_guide-ICN pdf Billing Mnitring Handbk 28 Revised

34 Nvitas' Slutins Evaluatin and Management Center Resurces OIG: Cding Trends f Medicare Evaluatin and Management Services (May 2012) The Medical Recrd The medical recrd shuld be cmplete and legible. Dcumentatin f each patient encunter shuld include: Reasn fr the encunter (Chief cmplaint (CC) and Histry f Present Illness (HPI)) and relevant histry, physical examinatin findings and prir diagnstic test results; Assessment, clinical impressin r diagnsis; Plan fr care; Date and legible identity f the prvider entering the infrmatin, including their prfessinal credentials (i.e., MD, DO, MS, ARNP, PA, RN, etc.); and Patient s name, MRN, date f service n each page f the medical recrd. If nt dcumented, the ratinale fr rdering diagnstic and ther ancillary services shuld be easily inferred. Past and present diagnses shuld be accessible t the treating and r cnsulting physician. Apprpriate health risk factrs shuld be identified. The patient s prgress, respnse t and changes in treatment, and revisin f diagnsis shuld be dcumented. Dcumentatin shuld supprt the CPT/HCPCS and ICD-9-CM cdes reprted n the health insurance claim frm r billing statement. Key Cmpnents f an E/M Service Histry, Examinatin and Medical Decisin Making NOTE: Certain patients (e.g., infants, children, pregnant wmen,) may have additinal r mdified infrmatin recrded in the histry and examinatin areas. OR Time The visit is either dcumented as cnsisting predminately (mre than 50% physician patient and/r family face-t-face encunter) f cunseling r crdinatin f care; r, the E/M service is a time-based cde (e.g., critical care, prlnged services. etc.) In additin t time, there must be sme dcumentatin f the services prvided. 2. E/M and/r In-ffice Prcedures and Diagnstic Tests Wrksheet As applicable and used as a reference fr manual auditing Purpse Appendix C-1. Use fr each encunter mnitred that invlves E/M services, minr prcedures, inffice prcedures and/r clinical labratry tests. E/M services include, but are nt limited t inpatient hspital visits, ffice visits, nursing hme visits, cnsultatins, critical care services, etc. Minr prcedures include, but are nt limited t, minr surgical prcedures (i.e., stitches, injectins, etc.). In-ffice diagnstic tests d nt include invasive prcedures, X-rays, r diagnstic endscpies etc. Reference Nvitas E/M Cding and Dcumentatin Reference Guide. Appendix C-2. Use fr mnitring Ophthalmlgy and in-ffice prcedures and diagnstic services. Appendix D-1. Use when mnitring the Medicare Initial Preventive Physical Exam (IPPE). Appendix D-2. Use when mnitring Texas Medicaid Texas Health Step exams. Appendix D-3. Use when mnitring Medicare Annual Wellness Visits (AWV). Appendices E. Use when the 1997 E/M Dcumentatin Guidelines used t determine the level f physical examinatin services mnitred; r, fr Medicare Wmen s Preventive Exam (Pelvic/Pap G0101). Instructins (Appendix C-1) Billing Mnitring Handbk 29 Revised

35 Patient encunter infrmatin may be placed in the tp left-hand crner f Appendix C-1. Cding Outcmes Bx CPT Crrect: Fr nn-time based E/M services, cmplete Sectins 1-3 f Appendix C-1 t verify the level f the E/M service, listing the cde(s) that shuld have been used in the Pst-Audit CPT(s) bx. See Audit Scre Methdlgy Appendix M If the prcedure and/r E/M cde was cded at a lwer level than it shuld have been cded, r if the CPT cde was cded at a higher level than it shuld have been. refer t the Audit Scre Methdlgy This categry is t be used fr prcedures; when a cnsult was billed but did nt meet criteria therefre an E/M cde shuld have been billed (wrng E/M categry); r a wrng cde fr labratry service that results in a higher level f reimbursement than what we shuld have received. Anther example is when a patient was seen by a physician in the grup practice within the past 3 years and was billed as a new patient. Since the patient was seen in the clinic within the past 3 years, this shuld be cded as a subsequent visit. NOTE: This finding shuld nly be reprted if the physician, when infrmed that dcumentatin culd supprt a higher service, agrees with the finding. If the E/M cde is upcded by ne level due t inadequate dcumentatin (excluding Teaching Physician dcumentatin r if upcded by tw r mre levels refer t the Audit Scre Methdlgy Appendix M) If n dcumentatin exists at all t supprt the cde refer t the Audit Scre Methdlgy If the dcumentatin is insufficient t supprt the cde, i.e., the physician failed t dcument Chief Cmplaint which is required fr any E/M service, refer t Audit Scre Methdlgy a) Mdifier Crrect: Mark whether r nt the mdifier is crrect r if a mdifier was imprperly used r nt used when it shuld have been used, refer t Audit Scre Methdlgy. b) ICD-9 Crrect: Mark whether r nt the ICD-9 cde(s) are crrect. If the ICD-9 des nt accurately describe the cnditin r if the cde is nt cded t the highest level f specificity, r the ICD-9 fails t supprt medical necessity fr the service refer t Audit Scre Methdlgy. c) DOS Crrect: Mark whether r nt the Date f Service (DOS) billed is crrect, refer t Audit Scre Methdlgy. Teaching Dcumentatin Bx d) Resident: If a Resident is invlved, mark Yes n Appendix C-1.. e) Primary Care Exceptin (PCE): If services were prvided in a PCE clinic, mark Yes and make sure the requirements were met. Yu will need t review the calendar t verify the number f Residents being supervised and t cnfirm that the supervising physician was nt prviding any ther billable services while supervising the PCE Residents. If there were mre than 4 Residents r the supervising physician was prviding ther billable services, refer t Audit Scre Methdlgy, as thse Resident s services cannt be billed. f) Minr Prcedure/Diagnstic Scpe: Minr prcedures, thse that take less than 5 minutes t perfrm, and diagnstic scpes require the Teaching Physician s presence the entire time, frm insertin t remval f the scpe. Teaching Physician s presence (required fr the entire prcedure) can be dcumented by the Resident r Teaching Physician. If the answer is N refer t Audit Scre Methdlgy. g) Teaching Physician Dcumentatin (General Rule): Fr E/M services nt prvided in the PCE Setting, the Teaching Physician must persnally dcument his/her participatin in the key r critical prtin(s) f the service and management f the patient. The Resident's dcumentatin may nly be used t supprt the level f E/M service. If the Answer is N: Refer t Audit Scre Methdlgy. When Teaching Physician dcumentatin supprts a lwer level cde, (i.e., Teaching Physician fails t tie int Resident s nte, and therefre can nly cde based n Teaching Physician s dcumentatin). r if upcded by tw levels (i.e., cde billed was admissin, but due t lack f Billing Mnitring Handbk 30 Revised

36 reference t Resident dcumentatin, Teaching Physician s dcumentatin can nly be cded as CPT cde r reprt a subsequent hspital care cde that apprpriately reflects physician wrk and medical necessity fr the service) refer t Audit Scre Methdlgy. Fr mre infrmatin, reference Medicare Claims Prcessing Manual, Chapter 12 Physicians/Nnphysician Practitiner. Als reference MLN MM7405 Clarificatin f E/M Payment Plicy. h) POS (Place f Service): Mark Yes if the POS is cded crrectly; therwise mark N. The CPT cde must crrespnd with the crrect place f service cde. If POS is incrrect, refer t Audit Scre Methdlgy. Pst-Audit cdes: After determining the apprpriate cdes, recrd the pst-audit CPT(s), ICD-9(s) and refer t Audit Scre Methdlgy. Signature: Mark either Yes r N whether the prvider signed the dcumentatin apprpriately, including credentials, if the signature is inapprpriate; r if it was signed by anther prvider, refer t Audit Scre Methdlgy. i) Medicare Advance Beneficiary Ntice (ABN): If the patient is a Medicare beneficiary and services may be subject t denial as nt reasnable and necessary r exceed frequency limitatins, then an ABN is required. Please refer t CMS FFS Revised Advance Beneficiary ntice f Nncverage (ABN). If ne was nt btained in accrdance with CMS Plicy check?. If it des nt apply t this encunter, mark NA. j) Legibility: Indicate legibility f clinical dcumentatin If yu and tw ther peple are unable t read the nte, refer t Audit Scre Methdlgy. k) Incident T: If the patient is a Medicare beneficiary, and services were prvided by ancillary staff r a nn-physician prvider (NPP) incident t a physician s service, mark Yes. T qualify fr Medicare s incident t, the physician must be physically present during the first visit fr the new cnditin and he/she must be n site during subsequent visits. This will require a review f previus visits t verify if Medicare s cnditins were met. Please refer t CMS s Medicare Incident T requirements fr further guidance, Medicare IOM, , Chapter 15, Sectin 60. If Medicare s requirements were nt met r if services were prvided by ancillary staff (e.g., nurse visit) r prvided by a Medicare credentialed NPP, refer t Audit Scre Methdlgy. See Sectin 2.7 fr mre details f Medicare s requirements. l) Time-Based Cdes: If the CPT cde (including E/M) is time-based, mark Yes after Time-Based and indicate whether r nt time was dcumented by the Physician (nt a Resident). In this case, YOU DO NOT NEED TO COMPLETE SECTIONS 1-3 OF APPENDIX C-1, BUT CIRCLE THE CODE AS APPLICABLE. If it is a time based cde and the time was Nt dcumented, refer t Audit Scre Methdlgy. Cunseling/Crdinatin f Care: If the time-based cde is due t cunseling/crdinatin f care, then the fllwing shuld be dcumented: Ttal time; Time spent face-t-face with the patient during cunseling/crdinatin f care activities; and The general issues discussed with the patient. If any f these items are missing, the services must be cded based n the dcumented histry, exam and medical decisin-making (YOU MUST THEN COMPLETE SECTIONS 1-3 OF APPENDIX C- 1). If the cde is nt supprted by the dcumentatin, r upcded by ne; (upcded by tw r mre levels whichever is applicable, refer t Audit Scre Methdlgy. Was time dcumented? Indicate either Yes r N if the time is dcumented in the dcumentatin. If time is nt dcumented, the service must be billed as an E/M visit. if upcded the time is nt dcumented and it is a time-based service, refer t Audit Scre Methdlgy. m) Critical Care Services: In additin t dcumentatin f time by the physician (nt the Resident) the patient must als be critically ill as defined by CPT. Just because the patient is in the ICU des nt mean they have a critical cnditin supprting critical care cding. Als, a patient des nt have t be in a critical care unit t qualify fr critical care billing. Billing Mnitring Handbk 31 Revised

37 Fr critical care encunters invlving bth a Teaching Physician and a Resident, the Teaching Physician must persnally dcument: the time the Teaching Physician spent prviding critical care, that the patient was critically ill during the time the Teaching Physician saw the patient, what cnditins were being treated, and the nature f the treatment and management prvided by the Teaching Physician. Time spent in teaching cannt be cunted twards critical care. See Medicare Claims Prcessing Manual, IOM Pub , Chapter 12, Sectin Nvitas' Slutins E/M Definitin f Critical Care Services Mark either Yes r N if the service was Critical Care. Mark either Yes r N if the patient meets criteria fr critical as defined in CPT. If N, refer t Audit Scre Methdlgy. Critical Care includes many services. Mark either Yes r N if bundled services were billed inapprpriately, refer t Audit Scre Methdlgy. Select the E/M cde based n ttal time, type f visit, place f service and amunt f time which is shwn fr each cde. n) EMR/EHR: Was the dcumentatin inapprpriately clned? Mark N if the dcumentatin is clned apprpriately. If the dcumentatin is clned inapprpriately, mark Yes and refer t Audit Scre Methdlgy. Fr example, BC Plicy 7.2 states, The prvider may clne relevant prtins f the patient s previus nte entered by the same prvider r resident in that prvider s department t the extent it represents the level f wrk perfrmed by the prvider during the current visit and is revised t reflect any changes in the infrmatin. ) Cnflicting Histry Elements: Mark Yes if any element f the dcumentatin cnflicts with ther parts f the histry. If there are cnflicting elements, d nt cunt any cnflicting elements as histry. Fr example, chief cmplaint cnflicts with review f systems: CC states patient has an earache but ROS states n prblems with the ears, refer t Audit Scre Methdlgy. p) Cnsultatin Services: If the visit was billed as a cnsult, verify dcumentatin in the medical recrd f a written reprt. If n dcumentatin indicates reprt was sent t the requesting physician, mark N and refer t Audit Scre Methdlgy. As f January 1, 2010, Medicare n lnger reimburses cdes fr inpatient r utpatient services. Telehealth inpatient cnsultatins prvided t a patient in the hspital r skilled nursing facility setting shuld be billed with the apprpriate HCPCS cde. q) Were bundled services separately billed? If bundled services were perfrmed and billed but were nt a billable event r service, refer t Audit Scre Methdlgy. 3. Teaching Physician Rules Overall Teaching Physician Requirements The Teaching Physician rules ONLY APPLY where a Teaching Physician invlves a Resident in an apprved Graduate Medical Educatin (GME) prgram, nt a medical student, in the care f his/her patients. A GME Resident is an individual included in the TTUHSC s GME cunt. If yu have any questins regarding the status f a Resident, cntact J. Edward Bates, Senir Directr and Designated Institutinal Official fr GME at TTUHSC (806) The Teaching Physician rules d nt apply t Nurse Practitiners wh invlve Residents r student nurse practitiners in the care f their patients, r CRNAs wh supervise student nurse anesthetists. A Resident r Fellw wh is nt included in the GME cunt is nt classified as a Resident fr purpse f the Teaching Physician Rules. Hwever, the nn-gme Resident r Fellw must be separately credentialed with each payer in rder t bill fr his/her services. Neither the Teaching Physician nr Resident can refer (link t) r use a medical student s dcumentatin f Histry f Present Illness (HPI), Exam r Medical Decisin Making (MDM) t establish an E/M level f service. If the Resident has referenced the medical student's dcumentatin f HPI, Exam r MDM, Billing Mnitring Handbk 32 Revised

38 withut writing a separate nte, then the Teaching Physician must persnally dcument the HPI, exam and decisin making fr the level billed. The Resident and Teaching Physician can reference ancillary staff and/r medical student s dcumentatin f Chief Cmplaint, Review f Systems (ROS) and Past Family, Scial Histry (PFSH), which can be cunted in determining the level f service as t thse cmpnents f Histry nly. The Teaching Physician and Resident can als refer t ancillary staff r medical student s dcumentatin f vital signs, which can be used fr purpses f cunting the Cnstitutinal element under the Exam. In all cases, the Resident and/r Teaching Physician MUST separately dcument their wn findings f HPI, Exam and MDM. General Rule E/M Services (Nn-PCE Setting) The Teaching Physician s dcumentatin must link t the Resident s dcumentatin in rder t be able t cmbine the Resident s and Teaching Physician s dcumentatin t determine the level f service. The Teaching Physician must persnally dcument his participatin in r presence during the key r critical prtin(s) f the E/M service and in the management f the patient s care. See Appendix K fr Acceptable and Nn-Acceptable examples f Teaching Physician dcumentatin. The Teaching Physician s dcumentatin DOES NOT have t be verbatim identical t the examples in Appendix K. Als review CMS Transmittal 2303fr examples f minimally acceptable dcumentatin. Pre-Printed Statements: The use f pre-printed statements as a substitute fr persnal dcumentatin is insufficient. Prmpts may be used t assist in the cmpletin f the Teaching Physician s persnal dcumentatin f presence and participatin, but there must be persnal dcumentatin by the Physician as t his/her review f the histry; presence r perfrmance f the exam; and participatin in management f the patient s care. Electrnic Health Recrd (EHR) Macr Statements: An EHR macr is a cmmand in a cmputer r dictatin applicatin that autmatically inserts pre-determined text that is nt edited by the user. An electrnic macr may be used by the Teaching Physician in an EHR ONLY IF: IT IS PERSONALLY ADDED BY THE TEACHING PHYSICIAN IN A SECURED (PASSWORD PROTECTED) SYSTEM; and The Resident r Teaching Physician has prvided custmized infrmatin (patient specific) sufficient t supprt medical necessity. The nte must sufficiently describe the specific services furnished t the specific patient n the specific date. See IOM, , Chapter 12, Sectin 100. See Appendix L fr acceptable macrs that can be utilized in a TTUHSC EHR. Primary Care Exceptin (PCE) The Teaching Physician must be present at the clinic when the Resident perfrms the service, but des nt have t be physically present in the exam rm with the Resident (wh has mre than 6 mnths f training) and patient at the time f service. Teaching physicians may include residents with less than 6 mnths in a GME apprved residency prgram in the mix f fur residents under the teaching physician s supervisin. Hwever, the teaching physician must be physically present fr the critical and key prtins f services furnished by the resident with less than 6 mnths in a GME apprved residency prgram. That is, the primary care exceptin des nt apply in the case f residents with less than 6 mnths in a GME apprved residency prgram. See Medicare s Claims Prcessing Manual, Chapter 12, Sectin Subsectin C regarding PCE clinics. NOTE: The Teaching Physician cannt have any ther duties while supervising Residents under this exceptin, i.e., seeing private patients, supervising medical students, perfrming prcedures, etc. The Teaching Physician can perfrm administrative duties related t his/her duties under the PCE Rule. Billing Mnitring Handbk 33 Revised

39 Primary Care Exceptin (PCE) ONLY applies t lwer level E/M services ( ; ); Medicare IPPE (G0402); Medicare AWV (G0438, G0439) and Texas Health Steps (Medicaid) annual exams. PCE DOES NOT apply t prcedures. If the scheduled patient s prblem is mre cmplex than anticipated, the Teaching Physician may see the patient, but must meet the presence and dcumentatin requirements under the General Teaching Physician Rule t bill a higher level (i.e., 99204, 99205, 99214, r 99215). The key is that at the time the patient was scheduled, the cnditin was nt cnsidered cmplex (i.e., 99204, 99205, r 99215). Teaching Physician must persnally dcument that: He/she reviewed patient-specific infrmatin frm the Resident s ntes, including diagnstic tests, and The review ccurred with the Resident while the patient was in the clinic OR immediately after the Resident saw the patient, as applicable. Phrases such as Discussed and agree with Resident s assessment and plan are nt adequate. See Appendix K fr examples f unacceptable Teaching Physician dcumentatin. Dcumentatin must cntain patient-specific infrmatin. Als review CMS IOM chapter 12, Sectin B fr examples f minimally acceptable dcumentatin. Other Teaching Physician Rules Minr prcedures, i.e., less than 5 minutes, require Teaching Physician presence fr the entire prcedure. Teaching Physician presence can be dcumented by either the Resident r Teaching Physician. Dcumentatin fr diagnstic endscpic prcedures must reflect that the Teaching Physician was available during the entire prcedure, including insertin, viewing and remval f the scpe. Fr CMS infrmatin n physical presence, please refer t CMS IOM Chapter 12, Sectin 100; Definitins. 4. Review Level f E/M Services Only Appendix C-1 (and E, if Applicable) Purpse E/M Dcumentatin Guidelines: Yu may use either the 1995 r 1997 E/M Dcumentatin Guidelines t determine the level f E/M service. Cmplete Sectins 1-3 f Appendix C-1 fr any E/M service, ther than thse E/M services determined slely n dcumentatin f time (e.g., critical care cdes, discharge cdes, cunseling/crdinatin f care >50 percent f face-t-face time with the patient). Fr preventive services (e.g., annual examinatins), use Appendix D-1, D-2 r D3 as applicable. All wrksheets used fr mnitring/auditing are included in MDaudit. Manual Instructins Dcumentatin f Histry (Appendix C-1, Sectin 1) Chief Cmplaint (CC) Definitin A cncise statement describing the symptm, prblem cnditins, diagnsis, physician recmmended return (i.e., fllw-up fr cnditin/symptm/disease), r ther factrs that is the reasn fr the encunter, is usually stated in the patient s wrds. (Health Care Financing Administratin, 1997) The reasn fr the visit must be clearly evident in the Chief Cmplaint t understand why the patient requires care fr the service t be medically reasnable and necessary. CMS IOM Chapter 12, Sectin 100 r CMS MLN Evaluatin and Management Services Guide If the visit is fr fllw-up treatment f a knwn cnditin, then it is sufficient t nte fllw-up fr (listing the cmplaint/cnditin and the symptms that prmpted the visit). Fr example: Medical necessity is met if the physician states, Patient here fr medicatin refill fr hypertensin. That statement supprts the medical need fr that patient t be seen. Billing Mnitring Handbk 34 Revised

40 Subsequent inpatient hspital visits Patient s status as an inpatient is sufficient t supprt a chief cmplaint. Actin Mark Yes if there is a CC dcumented in the recrd and generally nte the CC; therwise mark N under CC. (NOTE: Using a mre specific/accurate CC is imprtant because the level f service f an encunter is apprpriately determined by using the RELEVANT elements f the Histry and Examinatin that are SPECIFIC t the nted CC.) If yu mark N fr the CC, then yu cannt cunt the HPI as an element f the exam, regardless f hw much ther histry is dcumented. If that results in insufficient dcumentatin t supprt the cde, refer t Audit Scre Methdlgy. Histry f Present Illness (HPI). Histry f Present Illness Definitin A chrnlgical descriptin f the develpment f the patient s present illness frm the first sign and/r symptm r frm the previus encunter t the present (frm CMS MLN Evaluatin and Management Services Guide). The prvider must btain this infrmatin which includes: Lcatin: A descriptin f specific place(s) n the patient s bdy where the symptm(s) are experienced. This can include a drawing with the lcatin marked. Statements: left, right, upper r lwer extremity, abdmen, head, etc. Example: Pt cmplains f abdminal pain Quality: A descriptin f hw the prblem feels, lks, behaves, such as acute, chrnic, stable, wrsening, imprving, etc. Statements: Sharp, crushing, crampy, stabbing, shting, tingling, etc. Example: Has felt a tingling sensatin in lwer extremities... Severity: A descriptin f hw the symptm(s) feel r hw bad the cnditin is t the patient. In sme cases the patient may grade the pain n a scale f 1 10 r describe it as lw, mderate, great r severe. Statement: Severe, mderate, minimal, imprving, intense, etc. Example: Rates pain at 7 n a scale f 1 10 Duratin: A descriptin f hw lng the patient has experienced the symptm(s), which may include infrmatin n when the symptm(s) first appeared. Statements: One week, fur days, pst surgery, etc. Example: Cmplaining f ear pain fr tw days Timing: A descriptin f when the patient experiences the symptm(s), such as cntinuus, daily, nly at night. Statements: Daily, cntinuus, cnstant, frequently, at night, etc. Example: Has been nauseus since last night Cntext: A descriptin f what caused r causes the patient t experience the symptm(s), r infrmatin that explains hw the prblem was identified. This includes fell during recess, shrtness f breath while running, fund during mnthly breast exam. Mdifying factrs: A descriptin f steps taken by the patient r things that makes the symptm(s) better r wrse. Statements: relieved by, exacerbated by, taken Tylenl fr pain, etc. Billing Mnitring Handbk 35 Revised

41 Assciated signs and symptms: A descriptin f any additinal sensatins r feelings experienced by the patient when the symptm(s) ccur. [This culd include elements that culd be used in the ROS, but can nly be cunted nce, either in the HPI r ROS.] Statements: Cmplains r denies, accmpanied by, etc. Examples: Pt cmplains f blurred visin with nset f headache. (Infrmatin digested frm the CPT Assistant Vlume 6, Issue 4, April 1996) Alternatively, the HPI can be dcumented thrugh the status f ne r mre chrnic cnditins, e.g., brittle diabetic, well-cntrlled asthma, chrnic lw back pain, etc. Medical necessity must be clearly dcumented t warrant the reasn fr the visit. Fr mre infrmatin, see CMS MLN Evaluatin and Management Services Guide Actin Mark each dcumented element and circle the level f HPI (as mre fully described belw) as either Brief r Extended. D nt cunt any element that cnflicts with the ROS and/r PFSH. Fr example if the HPI states dyspnea, but the ROS states negative fr the system, then d nt cunt either ne.. Refer t Audit Scre Methdlgy. Selecting the Type f HPI N HPI Dcumented: This includes instances where there is either n HPI r the Teaching Physician/Resident r NPP did nt dcument a separate HPI. In this case, there is insufficient dcumentatin t supprt any histry level fr purpses f determining level f service requiring 3 f 3 key cmpnents. At least ne HPI element must be dcumented fr any billable E/M service because all three key cmpnents must have at least the minimally acceptable level f dcumentatin accrding t payer guidelines. Review CMS 1995 guidelines fr mre infrmatin. Mark N under Cding Outcmes CPT Crrect Refer t Audit Scre Methdlgy. If the service cde nly requires 2 f 3 cmpnents (i.e., subsequent hspital visit, established ffice visit) and the exam and MDM are dcumented, DO NOT mark N fr lack f HPI. Brief: Circle if 1 3 elements r the status f 1-2 chrnic cnditins are dcumented. Extended HPI: Circle if 4 r mre elements r the status f 3 r mre chrnic cnditins are dcumented. Review f Systems (ROS) Definitin A ROS is an inventry f bdy systems btained thrugh a series f questins seeking t identify signs and/r symptms (nted as psitive r pertinent negative) that the patient may be experiencing r has experienced (Health Care Financing Administratin, 1997, nw CMS). This infrmatin may be btained by ancillary staff r thrugh use f a patient cmpleted questinnaire, but review by the prvider must be dcumented (e.g., signature and date; initial and date). Systems (r lack theref) include: Cnstitutinal: Symptm(s) r prblem(s) related t temperature (afebrile, fever), weight gain r lss, fatigue. Eyes: Symptms such as watering, itching, discharge, visin changes, histry f past eye exams, injuries r infectins, use f crrective lenses r diseases f the eye (i.e., glaucma, cataracts). Ears, Nse, Thrat (ENT) and Muth: Symptms in the ears, nse, thrat r muth, such as hearing prblems, nasal discharge r bleeding, sneezing, scratchy thrat, excessive salivatin, sense f smell r taste, past r present lesins, last dental exam, lss f teeth, etc. Respiratry: Breathing symptms, such as asthma, chrnic cughing, wheezing, brnchitis r pneumnia, etc. Cardivascular (CV): Heart and vascular system, such as heart palpitatins, sweating, excessive thirst, fainting, swelling f arms/legs, leg pain, hypertensin, chest pains, heart murmurs, pulse irregularities, etc. Billing Mnitring Handbk 36 Revised

42 Gastrintestinal (GI): Digestive system, including heartburn, swallwing difficulties, hiatal hernia, nausea and/r vmiting; gall bladder prblems, cnstipatin, diarrhea, hemrrhids, use f digestive aids including laxatives, hemcult exam results, if any, etc. Allergic/Immunlgic: Respnses related t the immunlgic system, such as HIV status, and symptms due t seasnal allergies, fd allergies, medicatin allergies, etc. Fr example, itchy, runny nse, fatigue, rash, hives, etc. Geniturinary (GU): The male r female reprductive system r urinary system, such as number f births, vaginal discharge, genital itching, libid, urinary prblems, tilet training (fr children), incntinence, etc. Hematlgic/Lymphatic: Respnses related t the lymphatic r hematlgic areas, such as anemia, bleeding, easy bruising r fatigue, bld transfusins, liver prblems, etc. Musculskeletal: Symptms r prblems experienced with the muscles, jints and tendns, such as muscle aches, jint pain/swelling/nise, spinal defrmity (sclisis), back pain, weakness, limitatins n mvement/activities, etc. Integumentary (skin and/r breast): Symptms/prblems n the skin r breast area, such as scars, mles, clr changes, lesins, last mammgraphy result (if relevant), pattern f breast selfexam, nipple discharge/changes, etc., breastfeeding (if relevant), etc. Neurlgical: Neurlgical experiences, such as fainting, seizure histry, anticnvulsant therapy, memry lss, hallucinatins, speech r language prblems, sensry r mtr disturbances, etc. Psychiatric: Any psychlgical cnditins r treatment, such as auditry hallucinatins, anxiety attacks, psychiatric cnditins (bi-plar, schizphrenic), etc. Endcrine: Respnses related t the endcrine system, such as thyrid disease, adrenal prblems r diabetes, unexplained changes in height r weight, increased appetite, thirst r urinary utput, heat r cld intlerance, giter, pancreatitis, etc. NOTE: This infrmatin may be cunted in either the ROS r HPI, but nt bth. (Digested frm Physician Practice Cder, March 1998) Actin Mark the dcumented elements and circle the level as described belw entitled ROS (Review f Systems). If there is a cnflict between the ROS and HPI r PFSH then d nt cunt either cnflicting statements. This is a greater risk with the advent f the EHR. Fr example, if the HPI states patient cmplains f fever fr 2 days and the ROS states n fever, then d nt cunt either item in either the HPI r ROS because they cnflict. Refer t Audit Scre Methdlgy if there is a cnflict between the ROS and HPI r PFSH. Selecting the Type f ROS N ROS: Circle N/A. Prblem Pertinent ROS: Circle Pertinent if at least 1 system related t the prblem(s) identified in the HPI is dcumented. Extended ROS: Circle Extended if 2 9 systems related t the prblem(s) identified in the HPI are dcumented. Cmplete ROS: Circle Cmplete if a minimum f 10 systems reviewed are dcumented. This can be dcumented as thse with psitive r pertinent negative respnses. Our Carrier will nt accept the phrase all ther systems are negative t meet a cmplete ROS each item must be dcumented separately. Past Medical, Family and Scial Histry (PFSH) Definitin the PFSH cnsists f a review f items in the fllwing areas: Past Medical Histry: A review f the patient s past experiences with illnesses, injuries and treatments (NOT OTHERWISE COUNTED IN THE ROS) that includes significant infrmatin abut: Billing Mnitring Handbk 37 Revised