NAMAS Webinar Q&A: EHRs: The Good, Bad and Unusual 07/09/19

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.

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Below are the questions received during our recent webinar, EHRs: The Good, Bad and Unusual, originally presented on July 9, 2019. These questions have been answered by the webinar presenter, Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CMRS, CMCS.

Question 1:
Coding for "consultation" versus "referral" is a topic of converation with providers. The terms are often used interchangeable in an EHR (P2P referrals). If a patient verbally tells the provider their PCP has referred them for a specific problem. Does this alone satisfy requirements for a consult request? Does the request from a provider have to specifically state that a consult is being requested or does the word "referral" simply imply a consult request in the EHR. How best to implement a policy for internal compliance plan?
Answer 1:
Consult requirements need 3 Rs - request from provider, render opinion, and return correspondence to requesting. The consulting provider is being asked for an opinion, and they may or may not initiate treatment at that visit. The intent, though, of a consult, is to render the opinion and send the patient back to the requesting provider. When the consulting provider takes over care of the problem, it becomes a transfer of care.

Question 2:
Don't the 95 and 97 guidelines state that a complete ROS can be credited if the pertinent positives and negatives be documented, then a statement of "all other systems negative" is acceptablef or a comp ROS?
Answer 2:
Yes, however, payors may interpret it differently. WPS, J5, currently allows this statement

Question 3:
so if physician didn't document any exam or ROS, coder should not query to ask physician if has notes to reference and add?
Answer 3:
Coder can query to verify the note is complete. It is not advisable to lead the provider by telling them what they need to complete.

Question 4:
When leveling the exam, when a provider lists out the cranial nerves and also documents deep tendon reflexes and or sensation, is it ok to split up the cranial nerves to support eyes and ENMT as separate organ systems?
Answer 4:
I am guessing you are referring to 1995 guidelines. As long as the individual elements are not being counted in two places, they could be.

Attached is the document: Counting the 1995 Exam, referrred to during the presentation. Many people asked for it.
Counting the 1995 exam.docx
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