I know that many of you find auditing the “worst of the worst” when performing coding duties in your office. But unfortunately, coding is a “necessary evil”. Over the next few weeks in the blog, I’ll be covering some of those “icky” issues of Auditing that we all struggle with. I'll go through with you from Top to Bottom the in's and out's of the audit process for CPT. In addition, I’ll be doing a 3-hour presentation at the AHIMA pre-conference in Grapevine, TX on October 4th from 2-5:00 p.m. Hopefully, I’ll get to see you there. …. Here we go….
The 4 T’s of auditing are
1. Talk: Which is comprised of the physician or provider having a discussion, or review of patient’s present illness(s)
a. CC = Chief Complaint
b. HPI = History of Present(ing) Illness
c. ROS = Review of Systems
d. PFSH = Past, Family,Social History(s)
2. Touch: Which means the physician or provider actively examined the patient. There has to be some form of “touch” i.e. the provider examined your ears with a scope, looked in your mouth, listened with a stethoscope to your heart/lungs, palpated, or felt your abdomen.
3. Think: This means the physician or provider has to determine what course of action to take and what diagnosis to give your symptoms during this visit. This is the most complex of all in auditing. As a coder you need to assess what the physician did to arrive at the diagnosis. Did the physician order lab work or x-rays, Did they prescribe a new medication, did they re-fill a previous prescription or medication, did they prescribe physicial therapy, or maybe even determine surgery is required.
4. Time: To me, TIME is the gray-area factor that can be utilized if criteria is not met to bill the CPT code. If a physician or provider wishes to bill based upon time, documentation must support (and notate) that over 50% of the face to face time with the patient was spent in counseling and coordination of care. It is very helpful if the provider or physician explicitly states in their documentation that they spent XXX amount of time counseling the patient on “ABC123”
Each patient visit note, regardless where the patient care took place, should contain the basic 4-T’s, and be auditable within this criteria. If you put this 4-T process to the test, you’ll be amazed at how easily you can break down those “tough” documentations into easily work-able audits. I have also put below the actual CPT definition of how "time" is to be utilized within CPT.
Next week’s blog I’ll cover in detail all the essential elements of “talk” HAPPY CODING!!!
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