Many of the physician-designed charts are not, but need to be, in compliance with CMS's Documentation Guidelines for E/M Services – Ophthalmology uses the 1997 Guidelines (https://www.cms.gov/mlnedwebguide/25_emdoc.asp).
CHART DESIGN ASSESSMENT TIPS
- Base your design on a forced entry form for History and Examination components (See sample at www.RivaLeeAsbell.com).
- CC/HPI (Chief Complaint/History of Present Illness) should accommodate narrative description when necessary.
- ROS/PFSH (Review of Systems/Past, Family Social History) should use the nomenclature found in the guidelines and not disease entities. Each category has to be individually documented. The ROS includes current and past problems for coding purposes.
- Each Examination element has to be designated as normal or abnormal. There are 14 elements. Do not use automatic negative defaults.
- Use Medicare's terminology for elements of the examination. For example, Lids/Adnexa not L/C/S.
- Documentation of Medical Decision Making needs an Impression and Plan, each clearly delineated. Again, the design should accommodate a narrative description when pertinent.
COMPLIANCE ISSUES
HISTORY TAKING
- Intake of the HPI must be performed by the physician.
- The tech may do the initial intake of the ROS/PFSH but it must be reviewed by the physician and so noted in the chart.
- PSFH is actually three separate categories that need individual documentation: Past History, Family History and Social History.
- Medications should contain dosage information when possible.
- If a list of medicines is separate, always attach it to all requests for medical records.
- Make sure there is a way to update the baseline ROS/PFSH.
EXAMINATION
- Elements that are being counted toward the level of service have to be performed by the physician.
- Make sure each element can be noted as abnormal or normal and there is an area to describe abnormalities, if abnormal.
MEDICAL DECISION MAKING
- In order to support your level a narrative description may be needed.
- Be sure to include orders for diagnostic tests.
DIAGNOSTIC TESTS
- Almost all diagnostic tests that are disallowed under audit on the basis that the interpretation and report was insufficient or there is no order for the test.
- For each test billed there has to be a separate interpretation and report. This needs to be in narrative form or a template can be used.
- Extended ophthalmoscopy is an additional test and you cannot go from dilation to extended ophthalmoscopy and have it count as both the examination elements and the special test.
- In EMR it is difficult to meet the drawing requirements — rather one finds a simple childlike sketch that does not qualify.
SIGNATURES/SCRIBING
- Electronic Signatures
Advice from Medicare contractors suggests:
— Protection against modifications is stated
— You check with your attorneys and malpractice carriers
— Consider attaching a statement regarding protection of entries
- CERT Audits
When you submit medical records to the contractor with an electronic signature, you must also include a copy of the electronic signature protocol/procedure. The protocol/procedure should describe the requirements that the physician uses his own ID and password to enter the system to sign the medical records. (NGS Medicare)
- Scribe's Notes
Include:
— Name of scribe & legible signature
— Name of physician who dictated the notes and provided the service
— Date of service
— Name of patient
- Physician's Notes
Include:
— Affirmation the physician was present during the time the encounter was recorded
— Verification that he/she reviewed the information/Signature/Date
— Verification of the accuracy of the information
— Any additional information needed
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