CODING & DOCUMENTATION
Fam Pract Manag. 2021 Jul-Aug;28(4):32-33.
Author disclosure: no relevant financial affiliations.
- STAFF DOCUMENTATION OF THE PATIENT HISTORY
- MODIFIERS FOR MULTIPLE PROCEDURES
- COUNTING DATA FOR MEDICAL DECISION MAKING
- AWV WORK BY MEDICAL ASSISTANTS
- WHAT COUNTS WHEN ORDERING AND REVIEWING TESTS
STAFF DOCUMENTATION OF THE PATIENT HISTORY
Can I allow my clinical staff to document the entire patient history prior to my face-to-face evaluation and management (E/M) service and count that information toward my level of service?
The Centers for Medicare & Medicaid Services changed the E/M documentation guidelines for Medicare patients in 2019 to allow clinical staff to document the patient history as long as you review the information, update or supplement it as necessary, and document that you have done so. However, other payers may still require that physicians personally perform and document the history of present illness based on the 1995 or 1997 documentation guidelines. You may want to check with your payers.
MODIFIERS FOR MULTIPLE PROCEDURES
When I perform multiple procedural services (e.g., removing skin lesions from distinct body areas), I append modifier 59 (distinct procedure) to the lesser procedure. Is it also necessary to append modifier 51 (multiple procedures) to each secondary procedure code?
This may depend on the health plan, but most payers, including Medicare administrative contractors, have indicated that modifier 51 is no longer necessary but will be accepted when reported. Most automated claims adjudication systems recognize multiple procedures on the same date and apply associated reductions regardless of whether modifier 51 is included.
COUNTING DATA FOR MEDICAL DECISION MAKING
I was told that my office visit documentation must support that I performed activities from at least two of the bullet points listed as Category 1 data in the CPT medical decision making (MDM) table to fulfill any combination of two under that category. Is this correct? I do not see this in CPT guidelines.
No, it is not required that your activities come from a minimum of two different
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Send questions and comments to firstname.lastname@example.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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