CODING & DOCUMENTATION
Fam Pract Manag. 2010 Sep-Oct;17(5):36.
Documenting medication review
We use a medication list in the chart on which we note the patient's current medications and document any changes. On the physician encounter form, is it acceptable to include the statement “medication list reviewed” rather than actually writing out the medications?
Your documentation of “medication list reviewed” is likely acceptable as long as the medication list is also updated and signed by the physician. Remember to include a copy of the medication list documentation when responding to any record requests. Physician review of medications is part of the past history (the P in the past/family/social history, or PFSH), about which the Documentation Guidelines for Evaluation and Management Services has this to say:
“A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by ... describing any new ROS and/or PFSH information or noting there has been no change in the information and noting the date and location of the earlier ROS and/or PFSH.”
It is also advisable to indicate where in the chart the referenced medication list may be found (e.g., “Medication list reviewed, see list under Medications tab”).
Pre-op medical clearance
How should I code a visit for one of my established Medicare patients who comes to my office for pre-op medical clearance requested by the surgeon? In the past I have used an outpatient consultation code. What should I use now that the new consultation coding rules are in place?
For your Medicare patients requiring pre-op clearance, you must now report an office or other outpatient evaluation and management (E/M) code (99201–99205 or, in your example, 99212–99215 since the patient is established). If the service is performed in the inpatient setting, an initial or subsequent hospital care code (99221–99223 or 99231–99233) should be used. Continue to follow CPT instructions for reporting consultation services for patients whose payers still accept the consultation codes.
Discharge and transfer to another hospital
If I transfer a patient from Hospital A to Hospital B, can I bill a discharge service code (99238–99239) even though the patient will be admitted on the same day to Hospital B?
This answer assumes the patient was an inpatient and not in observation. If you are providing both the discharge service at Hospital A and the initial hospital care at Hospital B on the same date or if a physician of the same specialty in the same group is providing care at Hospital B, a subsequent hospital care code (99231–99233), rather than a discharge service code, should be reported (see Chapter 12, Section 18.104.22.168 of the Medicare Claims Processing Manual for more information). Where neither you or a same-specialty member of your group practice will be providing care at Hospital B, the services of each physician could be reported.
Editor's note: While this department attempts to provide accurate information, some payers may not agree with our advice. You should refer to current CPT and ICD-9 coding manuals and payer policies.
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Send questions and comments to email@example.com, or add your comments below. While this department attempts to provide accurate information, some payers may not accept the advice given. Refer to the current CPT and ICD-10 coding manuals and payer policies.
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