What are the rules when it comes to completing chart notes after the time of service? Can doctors charge a copay for an annual exam?
Q: Our practice gives the providers 30 days to complete their notes. The charges go out the day after the patient is seen. I am concerned that we should be completing these charts more quickly than that. Is there a particular rule I can point to about this?
A: The current CMS online E&M guidance states that: "To maintain an accurate medical record, document services during the encounter or as soon as practicable after the encounter."
During, or soon after…this does not mean weeks! Local guidance from Medicare Administrative Contractor (MAC) in my state says:
"Medicare expects the documentation to be generated at the time of service or shortly thereafter. Delayed entries within a reasonable time frame (24-48 hrs.) are acceptable for purposes of clarification, error correction, the addition of information not initially available, and if certain unusual circumstances prevented the generation of the note at the time of service.
Every note must stand alone, i.e., the performed services must be documented at the outset. Delayed written explanations will be considered. They serve for clarification only and cannot be used to add and authenticate services billed not documented at the time of service or to retrospectively substantiate medical necessity. For that, the medical record must stand on its own with the original entry corroborating that the service was rendered and was medically necessary."
This one is quite clear, 24 - 48 hours or a reasonable time frame. I don't think you'd get much sympathy from Medicare if you asked them for even a one week delay. There's an easy way to find out.
You can just submit a FAQ to your MAC - pick an interval, one week, two weeks, three weeks - I can about guarantee you that they will not look kindly on any of those as acceptable time frames for record completion.
Q:Some of my doctors collect copays from patients that come in for annual exams. Of course, those are preventive and they should not be doing it. The answer I was given is that many times the patient then presents with a problem at the same time so then it is not an annual, and such, they felt they could collect the copay.
My question to you is should they be doing that? I think they can code for an annual with a modifier for the other issue.
A: It sounds like they know in advance whether or not the patient has problems that require assessment or treatment beyond the health maintenance portion of the visit.
If so, that's actually a good thing, and it is appropriate that they collect the copay.
If however, they are collecting on patients whom they don't know will have a medical problem addressed, this is a problem. Do they collect a copay in all annual visits? That would certainly shade this towards the latter, inappropriate scenario. Recognize that the copay is applicable only to the additional E&M codes for problems addressed. Without that, do not charge a copay.
Q:What are the general rules behind coding a Z00.00 in the "Adult Primary Care" setting? Is the "Annual Physical Visit" the time to address all of the patient's chronic conditions, and therefore chart diagnosis codes for all conditions discussed during the visit?
For example: The patient has a visit for an annual physical. Past medical history is diabetes, hypertension, hyperlipidemia, and a BMI of 38.0. The provider reviews labs, or maybe writes orders for labs to check the status of the diabetes and hyperlipidemia, reorders medications for the hypertension, and discusses diet for the diabetes, hyperlipidemia and BMI issue.
Would the coding for this visit not only be Z00.00, but also I10 for the HTN, E.78.2 for the Hyperlipidemia, and E11.65 for the DM and Z68.38 for the BMI?
Would there ever be a reason to NOT include those pre-existing condition diagnosis codes on the claim, along with the Z00.00, if there was documentation that they were addressed at the visit?
A: Five questions in one! Let's answer them one at a time.
A. Z00.00 is an encounter for general adult medical examination without abnormal findings. This code is used to represent the preventive 'portion' of the encounter. The 'without findings' piece pertains to new findings of signs and symptoms, and not any chronic conditions that may be addressed separately.
B. Another part of your question, is annual 'the time." This is up to the physician, with different physicians going about it different. You can certainly have the patient come back to deal with problems separately, or you can do them in the same encounter - there is no right or wrong about it, only various considerations for each option.
C. "And therefore list all diagnosis codes for all conditions discussed." This is over-broad. If you do an annual and address problems then you report those codes.
The rule for what is reportable is "Also Code Any Coexisting Conditions Relevant to the Encounter (i.e., Conditions that Require or Affect Patient Care Treatment or Management)." This would include any problems assessed and documented, not just 'discussed.'
D. On your example - you have the correct codes assuming you have the detail correct on the Lipids and DM.
E. As to a reason not to code them all, I can't speak for all payers, contracts and arrangements, but per ICD-10 and general coding guidance, if they were assessed and documented as such, they are reportable.