E & M Visit Q & A – Do physician required to document the date in Medical record – Observation care?

Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time?

A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:

For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.

Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?
A. It is mandatory that the physician’s documentation clearly indicates that the forms have been reviewed by him/her, and that any follow-up on positive and pertinent negative responses is documented.

Q. Can I document the most clinically relevant systems and then say “all other systems reviewed are negative” in order to qualify for a complete (10 system) ROS?
A. This would be allowed if all other systems were, indeed, reviewed and are negative, and if a complete ROS is medically necessary.

Q. If the patient’s medical record indicates that the PFSH is “non-contributing” with regard to the patient’s condition, does this documentation support that the PFSH was reviewed?
A. If the record indicates that the patient’s past, family, and social history (PFSH) is “non-contributing,” it may be inferred that the practitioner did not ask the patient about his or her PFSH. However, if the practitioner has reviewed the patient’s PFSH, it should be documented in the medical record.

Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”

A. Yes — when referring to previous notes, specific information must be given regarding when and where.

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