Can anyone provide any guidance on how your company will be handling 2019 Medicare Physician Fee Schedule change regarding practitioners not needing to re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and update it as needed?
Does this include both history and exam elements? Also, if the practitioner does state that they have reviewed prior data, and nothing has changed since the last visit, would you count those history and exam elements from the previous visit that have not changed for the current date of service?
Thank you in advance!
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Your question has been answered by Shannon O. DeConda, CPC, CEMC, CEMA, CPMA, CRTT
Our stated position is that while this is a tempting offer, prior to adapting your organizations opinion- you should consider the impact.
Currently, we are expected to paint a portrait of the patient so that one encounter has medical necessity to support orders, surgical interventions, and even the level of service billed. If you begin to allow providers to refer to bits and pieces of documentation elsewhere, you will now be required to justify services over multiple encounters, and potentially with only nuggets here and there of why.
We would recommend that organizations truly evaluate this impact on compliance risk prior to allowing providers to change their documentation processes.