Question: Can you recommend a template (from chief complaint to plan) for 'Wellness Exam' V70.0 visits we can use a frame work for our documentation?
Answer: I recommend using forms similar to the EPSDT forms that are provided by the federal government. Here is a link to the ones we use in Oklahoma. If you use these, typically most states will agree that you fulfill the documentation guidelines. The well forms for age 0-20 are CH-1 through CH-15:
http://okhca.org/providers.aspx?id=120
I don't have any forms for adults over 20 years old. Most likely, your state's Medicaid site may have some forms similar to these that they recommend. Hope this helps. If you want to make a template similar to these, mainly you need to adjust the components to make them appropriate for any particular age. Pay particular attention to keeping sections that have to do with "age-and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures" because that is the language used in the descriptors for 99381-99397. You do not have to have the components of 99201-99205 E&M exams (certain amount of CC, HPI, ROS, PMFSH, Exam, Decision Making)-those requirements do not apply to "Preventive Medicine Visits".
Question: My biller and I are having a disagreement re: what can be considered management and treatment options for medical decision making. We agree on referrals, meds, PT/OT, etc
But when you write (in your 2011 CME) patient instructions and nursing instructions she is more conservative.
for example:
Rest, heat, elevation, out of work three days No walking except for crutches and gel splint for 3 days FU in one week if any concerns and will consider Xray if not better; FU sooner if sx worsen
I would consider two or three different treatment options and she would just say one patient instruction for all of that.
Answer: Unfortunately, this is a difficult question. If you look in the 2014 CPT guidelines, you will find no answers. If you look in the 1995 or 1997 E&M guidelines published by Medicare, you will also find no help. I have seen several auditing tools used by different Medicare/Medicaid carriers across multiple states and many of them have their own tools that they use internally. Unfortunately, they do not even agree with each other.
Here is my advice:
More than likely, the auditor you need to fear is whomever your Medicare/Medicaid payer is for your region. Contact them and find out what kind of auditing tools they use in order to score and document Medical Decision Making, especially as it relates to Diagnosis and Management Options. Because in reality it doesn't matter what my opinion, your opinion, or your biller's opinion is if you end up losing an audit. The only opinion that counts is the opinion of the person conducting the audit. So find out what their rules are and abide by them.
I know that this may not be very helpful, but as we discussed in the course Management Options are not defined in the coding guidelines. So it is truly up to the discretion of your payer (unfortunately).