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  1. Please define correct coding for an established patient office visit, in which there is documentation of history and MDM, but no examination is performed.

    Answer: Established patient visits generally require 2/3 components. CMS does not specify which of the three components are necessary, so any of the two are generally acceptable. Of note, a note with a history and exam, lacking a medical decision or plan of care, often cannot support the medical necessity of the visit. Updated 8/29/2017

  2. When a service is documented as a chief complaint without an HPI, a completed exam, and an assessment without a plan, is it a billable service?

    Answer: In the situation described, there appears to be documentation of only one element, i.e., examination. Since there is no documented history or MDM, medical necessity for the service cannot be supported and the service does not appear to be billable. Updated 8/29/2017
  3. Please advise on whether documentation by a student nurse, cosigned by a staff RN, is sufficient to support a hospital facility fee.

    Answer: A nursing student’s documentation may not be used to support a billed service to Medicare. In order to bill the facility fee, a nurse employed by the hospital must document the service. Updated 2/8/2018

  4. How long does a provider have to complete a note? When do you consider a note incomplete?

    Answer:
    Providers are expected to complete service documentation “during or as soon as practicable after it is provided in order to maintain an accurate medical record” although CMS does not define a specific timeframe. (CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.1 [1 MB]) 

    A note is incomplete when it does not support the elements of care represented by the billing code and is not dated and signed clearly by the performing provider.

    Generally speaking, the service should be documented on the same date on which it is performed, since the documentation of date and signature must correlate to the date of service on the submitted claim. Updated 6/9/2017
     
  5. If there are not two patient identifiers on the medical record documentation when reviewed, will the service be paid? Are the any requirements for patient identifiers?

    Answer:
    NGS Medical Review will accept one patient identifier on a record, usually the patient’s name and/or HICN. Updated 6/9/2017
     
  6. How should time be recorded in the medical record?

    Answer:
    Although CMS does not define a specific time recording rule, NGS strongly recommends that time spent rendering a service(s) is included in the associated notes. The preferred format is “11am-11:45am” although “Time spent: 45 minutes” may also be acceptable. Updated 6/9/2017
     
  7. With EHR, what does NGS give credit for if notes are “cloned” from one visit to the next? Does NGS look for any specific documentation from the provider in order to give credit for past medical, family and social history?

    Answer:
    Cloned notes are strongly discouraged, unless there is clear documentation that the examiner has reviewed the prior material with the patient and updated it as necessary. When PFSH is copied from a prior visit note, the examiner is obliged to indicate that it has been reviewed with the patient and updated as necessary. Bringing prior verbiage forward into a new note must be medically necessary and pertinent to the encounter; adding voluminous verbiage from prior visits is usually not medically necessary. Updated 6/9/2017
     
  8. When reviewing documentation, should the diagnosis always be listed in the assessment and plan? Or will they allow it to be extracted from the note?

    Answer:
    For the purpose of clarity, the diagnosis should be listed in the assessment and plan, especially since the number and complexity of diagnoses will be factored into the level of complexity for the visit. The patient’s chief complaint may include reference to the diagnosis, or may be phrased in the patient’s own words as the reason for the visit, but the diagnosis billed on the claim is expected to be clearly stated in the provider’s assessment and plan. Updated 6/9/2017

  9. When records are requested for NGS Medical Review, what should be submitted to support reference to information documented at a previous encounter?

    Answer: When submitting records for NGS Medical Review in which previously recorded information is referenced, both records must be submitted in order to assess the correct level of coding for the service in question. Updated 3/1/2019

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