If you're not billing higher level evaluation & management services because your physician glosses over a patient's PMFSH, you could be missing out on your reimbursements.
Here are some medical billing tips to ensure your physician is capturing and you are recognizing every history component the patient points out:
First, find out the PMFSH level – none, pertinent and complete
For medical coding and billing ( Source "http://www.supercoder.com") purposes, the history part of an evaluation & management service needs these three elements – history of present illness (HPI), review of systems (ROS), and past medical, family and social history (PMFSH). As such, the PMFSH helps determine patient history level, which has a huge impact on the evaluation & management level you report. Not knowing the PMFSH level will mean you'll not be able to decide which level of evaluation & management code you should report on the claim.
Second, zoom in on a code based on the PMFSH Element Requirement
After you determine the level of PMFSH contained in your physician's documentation, you can see which codes that history element supports.
Note of caution: If your physician doesn't document any PMFSH elements, you can only reach an extended problem-focused level of history; this means the highest codes you will be able to report are a level-two new patient code or a three-level established patient code. In order to get a level-four and level five new patient visits and level-five established patient visits, it's essential to have an all-encompassing level of history.
Third, do not neglect these areas
As per evaluation & management guidelines, if a patient's past medical, family and social history has not changed since a prior visit, your physician need not document the information once more. However, it's important that he documents that he reviewed the prior information in order to ensure it's up to date and also note in the present encounter's documentation on the date and place of the initial prior acquisition of the PMFSH. In fact if you neglect any of these criteria, some payers will give no PMFSH credit.
Here are some medical billing tips to ensure your physician is capturing and you are recognizing every history component the patient points out:
First, find out the PMFSH level – none, pertinent and complete
For medical coding and billing ( Source "http://www.supercoder.com") purposes, the history part of an evaluation & management service needs these three elements – history of present illness (HPI), review of systems (ROS), and past medical, family and social history (PMFSH). As such, the PMFSH helps determine patient history level, which has a huge impact on the evaluation & management level you report. Not knowing the PMFSH level will mean you'll not be able to decide which level of evaluation & management code you should report on the claim.
Second, zoom in on a code based on the PMFSH Element Requirement
After you determine the level of PMFSH contained in your physician's documentation, you can see which codes that history element supports.
Note of caution: If your physician doesn't document any PMFSH elements, you can only reach an extended problem-focused level of history; this means the highest codes you will be able to report are a level-two new patient code or a three-level established patient code. In order to get a level-four and level five new patient visits and level-five established patient visits, it's essential to have an all-encompassing level of history.
Third, do not neglect these areas
As per evaluation & management guidelines, if a patient's past medical, family and social history has not changed since a prior visit, your physician need not document the information once more. However, it's important that he documents that he reviewed the prior information in order to ensure it's up to date and also note in the present encounter's documentation on the date and place of the initial prior acquisition of the PMFSH. In fact if you neglect any of these criteria, some payers will give no PMFSH credit.
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