Please see this free resource for ophthalmology.
An excellent resource for optometry billing and coding guide and cheat sheet for optometrists just starting out or for experienced ODs who want a thorough refresher. Knowing the difference between routine and medical plans, what copays may be applicable to visits, or how deductibles will affect...
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So what is your “requirement” for a timely signature? Check with your MAC.
The CMS/Medicare policy manual is specifically vague to allow the regional MAC’s medical directors the opportunity to set policy for their regions. As a result, the answer as to timing varies from region-to-region.
Timely Completion and Signing of Medical Records
This issue has both billing and compliance ramifications.
For billing purposes, Medicare generally requires the following:
1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
- Reason for the encounter and relevant patient history, physical examination findings and prior diagnostic test results;
- Assessment, clinical impression or diagnosis;
- A plan for care; and
- A date and legible identity of the observer.
Coding Corner The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private...
www.acoi.org
Ancillary staff and/or patient documentation is the process of non-physicians and non-advanced practice providers (APPs) documenting clinical services, including
history of present illness (HPI), social history, family history and review of systems in a patient's electronic health record (EHR)
Medicare documentation requirements changed in November 2018 and now allow physicians to verify in the medical record staff or patient documentation of components of E/M services, rather than redocumentation of the work if this is consistent with state and institutional policies.
January 2021 Medicare documentation requirements were further simplified: when billing by content (as opposed to time) medical decision-making is the only component that drives the level of service determination.
Starting Jan. 1, 2021, the level of service is not determined by the history of present illness, social history, family history, review of systems or physical exam. These items may still warrant documentation for clinical purposes. There are no restrictions as to who can input this information into the patient’s record. Thus elements could be entered by the patient, a clerical assistant, a medical assistant or other clinician.
The 2021 Calendar Year Medicare Physician Fee Schedule allows a physician to determine the level of service based on either medical decision making (when billing by content) or by time. There is no requirement that the documentation be physically performed by the billing practitioner and no requirement to redocument information entered by a non-billing practitioner.
Ancillary staff and/or patient documentation is the process of non-physicians and non-advanced practice providers (APPs) documenting clinical services.
www.ama-assn.org
Coding Resources: There are many resources available. Bookmark these for future reference when you need help coding. Best advice I was given was make Google your new BFF. But BEWARE know your source & always check dates as coding changes frequently & a good coder needs to stay current in...
www.cco.community
