Week 4 Flashcards
(27 cards)
What should be clearly identified in the record in the initial visit?
chief complaint history of present illness family history past health history treatment/document physical examination diagnosis treatment plan
chief complaint
patient’s stated reason for the encounter
clearly indicates symptom, problem or condition
concise
history of present illness (HPI)
mechanism of history
quality and character of symptoms/problem
onset, duration, intensity, frequency, location and radiation of symptoms
aggravating or relieving factors
prior interventions, treatments, medications, secondary complaints
symptoms causing patients to seek treatment
what other things should you include in the HPI?
review of medications
allergies
review of labs and procedure results
review of outside consultation reports
presenting complaint, including the severeity and duration of symptoms
new concern or ongoing/recurring problem
chagnes in patient’s progress or health status since last visit
past health history
general health, prior illness, hospitalizations, allergies, medications, or surgeries
identify any contraindication to care
what are the extra things you need to record for medicare past health history?
social history
ongoing/recurring health concerns
patient risk factors
physical examination
vital signs ROM level of muscle spasm performance relative to ortho/neurotesting whatever else is an objective finding focus on presenting complaint (PART) positive physical findings significant physical findings as related to CC ROS
diagnosis
communicating to payers what is wrong with the patient and where the problem is located
use ICD-10-CM to code diagnosis
treatment plan
length or duration frequency of treatment what will be done why it will be done how it will be measured how will you know if it is working back up plan, refer out?
what does medicare say about treatment plans?
acute problems may require as many as 3 months of treatment
some require very little treatment
more frequent at first, then decrease frequency with time or as improvement is obtained
complicating facotrs that can increase time
symptoms present more than 8 days skeletal anomaly structural anomaly severe pain injury because of pre-existing conditions, underlying pathologies, congenital anomalies
what if patient returns with same symptoms 31 or more days later
start over new history new exam new diagnosis new treatment plan
if medical necessity has not been proven, what happens?
MAC will reject claim and will not pay
DC should have an ABN on file in order to bill patient
if medical necessity has not been proven after payment has been made, what will happen?
MAC will demand that the payment will be refunded with interest
will other payers accept medicare definition of medical necessity?
maybe, maybe not
what do you need to prove medical necessity
history of onset patient complaint exam findings diagnosis treatment plan progress
standards for paperwork
chart/file should be in chronological order
if it’s not written, it didn’t happen
should contain standard abbreviations
anyone viewing the chart should be able to quickly understand the logic and course of treatment
outside reports should be read, dated and signed
6 components of oriented medical record
- complete problem list with each item dated and numbered
- determine diagnosis for each problem being treated
- establish speciific treatment goals for each problem
- prepare a written treatment plan for each active problem
- use the SOAP format for ongoing treatments
- document the resolution and/or referral dates for each complaint
what should you do for corrections to paperwork?
only be in the form of additions
draw single line through innaccurate information, note location of correct information, sign and date alteration
do it chonologically by date info is acually entered in chart
may use addendum with additional information
cross-reference the correct and incorrect enteries
other things that need to be documented
interactions between staff and patient that could potentially affect patient care
patient’s intent to not follow recommendations
telephone calls
appointment cancellations and no-shows
what modifiers and codes does medicare reimburse for?
98940, -1, -2
AT
GA
when is GY used?
when the service is excluded from consideration for payment
when is GX used?
ABN has voluntarily been signed
patient has financial responsibility
when is AT used?
active, restorative, arrest of progression or corrective care
