CMS 2019 Final Policy States:
• For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
When CMS states “what has changed since the last visit” what are you considering the last visit to be? Would the last visit be the immediate previous visit that took place or would the last visit apply to visits from 2 or 3 visits ago?
Also, we are wanting to make an internal policy about how many times in a row the provider can refer to a previous visit. I am worried that this new guideline will cause the providers to feel like they can put this on every single note causing a domino effect that would make one have to go back multiple visits to find the note they are actually referring to.
Thank you in advance for your help.
Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.
1 post • Page 1 of 1