"Negative" or "No Significant Past Medical History" are not acceptable phrases for Medicare billing for Past Medical History/Surgical History/Family Hisotry/Social History.
BAD: No Significant Past Medical History
BAD: Not Significant
BAD: Reviewed in Chart
GOOD: Denies Past Medical History
GOOD: No Past Medical History
GOOD: See HPI / See Problem List ** (caveat: you must reference PMHx in the history, avoid the word significant)
Specific TIME is an important component of critical care billing.
BAD: 30-74 minutes of critical care performed
GOOD: In excess of 30 minutes of critical care performed
GOOD: x Minutes of critical care performed
GOOD: In excess of 74 minutes of critical care performed
Don't Forget: to add "excluding teaching time or time performing procedures"
That's a wrap folks. We are doing better but I have seen SEVERAL slip ups on the past medical history issue.
Like it or not ICD-10 was introduced by CMS last year. Medicare has given a 1 year "grace" period to be more compliant with ICD-10 appropriate diagnoses. This grace period ends October 1, 2016.
We have been reminded to be "as specific as possible" when selecting our diagnoses. If the documentation supports a specific ICD-10 code, that diagnosis should be chosen. Sometimes, the unspecified code is all we may be able to diagnose. That is acceptable if our documentation supports that there is not enough clinical information to support a specific code.
GOOD: Facial Laceration
BAD: Abdominal pain
GOOD: Acute right lower quadrant pain
BAD: Chest Pain
GOOD: Acute chest pain
BETTER: Chest wall pain
THIS IS NOT LIMITED TO CHS.
This is mandated by Centers for Medicare and Medicaid Services (CMS)
One of our jobs with documenting is to help the coders bill our services to the appropriate level of service we provide. As tempting as it is to be frustrated by this, more often than not, charts and reimbursement are being under-coded. YOU can help by being thoughtful with the diagnoses you select.
My legal risk tolerance is to leave diagnoses unspecified if the exact cause is unknown. I frequently use "Chest Pain" as a diagnosis. I commonly document "that the exact etiology of the patient's [chest pain] is unclear." I will almost always add this statement to my undifferentiated patients of high risk.
I expect that this post will generate a good discussion on charting tips for our large subset of patients with unclear diagnoses. I'm looking forward to hearing what other folks will document to help our coders be compliant with ICD-10.
Disclaimer: Information contained in this blog is the opinion of the author and does not necessarily reflect the official opinion of Carolinas HealthCare System. Application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.