CODING & DOCUMENTATION
Fam Pract Manag. 2016 May-June;23(3):36.
Author disclosure: no relevant financial affiliations disclosed.
New-patient history requirements
Does Medicare's “Documentation Guidelines for Evaluation and Management Services” require a complete past, family, and social history (PFSH) for all new patient E/M services?
No. A complete PFSH is required only for those services that require a comprehensive history overall, such as level IV and level V new patient office visits. New patient office or other outpatient visits, observation services, initial hospital care, consultations, comprehensive nursing facility assessments, new patient domiciliary and new patient home visits must include all three PFSH elements to support a complete PFSH. A complete PFSH for established patient visits in the office, domiciliary or home, and emergency department requires only two PFSH elements.
Prolonged clinical staff services
When should prolonged clinical staff services be reported, and when does the time begin?
New for 2016, code 99415 is defined by CPT as “Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management (E/M) service in the office or outpatient setting, direct patient contact with physician supervision: first hour (list separately in addition to code for outpatient E/M service).” According to CPT, the total duration of the prolonged clinical staff service has to exceed 45 minutes to be billable. The service should be provided by clinical staff under the supervision of a physician or qualified health care professional, and the time of service must be documented. Including start and stop times is recommended.
For example, a physician orders oral rehydration for a patient that is to be administered over a two-hour period immediately following the office visit. The physician remains available in the office suite during the service and a nurse spends a total of 95 minutes face-to-face with the patient during the two hours. Let's assume
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