Evaluation and Management Services
In March 2002 the Medicare Carrier published the following article that articulates many of the documentation principles BWH’s Billing Compliance Department has been emphasizing in its training sessions. The concepts regarding concurrent consultant care in the inpatient setting, continue to be relevant and are worthy of repeating.
“Reviewers noted that medical record documentation for subsequent hospital care services did not clearly demonstrate the medical necessity of daily care services by a specialist in addition to the patient’s attending physician. Concurrent care services are reimbursed only when services of each physician (usually of different specialties) is required to play an active role in the patient’s treatment for a specific condition(s). Services by one physician cannot be reimbursed if they are duplicative of services provided by another physician.”
“Medical record documentation for each patient encounter should contain the following:
- Specific reason for the encounter, relevant history, physical examination findings and prior diagnostic test results;
- Assessment, clinical impression of diagnosis;
- Plan for care;
- Rationale for ordering diagnosis and ancillary services;
- Patient progress, response to and changes in treatment, and revision of diagnosis; and
- Date and identity of the observer (signature of rendering provider)”
If you have any questions contact: Neil Walsh in the Billing Compliance Department at 617-732-9377 or via email (cwalsh6@partners.org).