Faculty and Staff: For Your Benefit

Medical Billing Compliance Tip of the Month: November 2015

Physician Billing Compliance Tip

Coding Tip: Evaluation and Management Services

You DO NOT need to re-record a Review of Systems (ROS) if there is an earlier version available in the chart. It is acceptable to review the old ROS and note any changes. In order to use this shortcut, you must note the date and location of the previous ROS, and comment on any changes in the body of the current note. For example, if you are seeing an established patient in the office you can document:

• “A complete ROS, which was performed during a previous encounter was re-examined and reviewed with the patient. There is nothing new to add, today. For details, please refer to my previous note in this chart, dated 11/23/2014.

Hospital Billing Compliance Tip

Observation Services

Outpatient observation services require monitoring by a physician and other ancillary staff, which are reasonable and necessary to evaluate the patient’s condition. These services are only considered medically necessary when performed under a specific signed order of a physician.

Outpatient observation services are not to be used for the convenience of the hospital, its physicians, patients, patients’ families, or while awaiting placement to another facility.

Outpatient observation services generally do not exceed 24 hours. Some patients may require a second day of observation up to a maximum of 48 hours.

More Billing Compliance Tips can be found at www.obc.med.miami.edu