CODING & DOCUMENTATION

 

Fam Pract Manag. 2019 Jan-Feb;26(1):30.

Author disclosure: no relevant financial affiliations disclosed.

PRESCRIPTION DRUG MANAGEMENT AND E/M CODE SELECTION

Q

For the purpose of selecting an E/M code, what level of medical decision making is associated with advising a patient to stop a medication?

A

Any management of prescription medication (other than simply acting on a payer notice regarding a formulary change) qualifies as moderate risk, according to Medicare's Documentation Guidelines for Evaluation and Management Services. If the level of diagnosis and management options considered or the amount and complexity of data reviewed is also moderate or high, this would support a moderate level of medical decision making overall.

REVIEW OF SYSTEMS: HOW MANY SYSTEMS ARE TOO MANY?

Q

My colleague advises always documenting a complete review of systems. However, this practice often provides little meaningful information. Is it recommended for coding and documentation purposes?

A

No. A complete review of systems (10 or more systems) is only necessary if the patient presentation calls for a comprehensive history. In such cases, documenting a complete review of systems helps support the comprehensive history required for billing services such as level-five established patient office visits, level-four or level-five new patient office visits, and level-two or level-three initial hospital or observation care. You should consider only medically necessary documentation when selecting the level of service. A review of two to nine systems noting any positive and pertinent negative findings is often sufficient.

DOCUMENTING EXAMS BY MEDICAL STUDENTS

Q

Under Medicare's rules for medical review of student documentation, what must a teaching physician document when he or she agrees with the exam findings, assessment, and plan noted by the student?

A

According to Medicare, after personally re-performing the exam and medical

ABOUT THE AUTHOR

Cindy Hughes is an independent consulting editor based in El Dorado, Kan., and a contributing editor to FPM.

Author disclosure: no relevant financial affiliations disclosed.

WE WANT TO HEAR FROM YOU

Send questions and comments to fpmedit@aafp.org, 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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