Need resource for minimal documentation required

[Nonphysiologic]

Hi All,

Is there a source to find out what exactly must be minimally documented both on HPI as well as EXAM to approve various procedures as well as medications? For example, what must be demonstrated or trialed to have a lumbar epidural approved by medicare as well as commercial insurances? Or what do I need to document to exactly to justify Nucynta instead of Hydrocodone.

Also, what are the minimum documentation that I need to have in each follow up for patient on chronic opioids? I know checking MIPS and occasional UDS is required but how often do I have to document a PHQ-9 or depression screen, opioid risk tool, functionality.....etc. It seems laborious to document that every single visit.

As I posted earlier I am helping implement EHR into our practice so I want to make sure we have all our bases covered every visit.

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[cowboydoc]

Unfortunately, I think you are asking the wrong question. Less documentation will lead to more denials, P2Ps, etc. I'd focus on efficently stacking the deck with any and all information insurance will require to approve said treatment plan. We have devolved to HS grads checking our work and bring a roadblock to care delivery.

You can easily set up templates to hit the ever changing points of insurance requirements, pt. Education, consents, etc.

Regarding E&M, CMS publishes requirements for documentation/medical complexity for billing codes. You'd be well served to learn this, make templates to get comprehensive info into your note automatically (and then find an area to sneak in clinically relevant info to communicate youth other physicians.)

 

[Ferrismonk]

For procedures, you may want to look at Evicore guidelines, those usually are crappy enough that if you follow their algorithm most will get approved. Regarding physical exam, usually you need 3 exams/findings suggestive of the pathology you want to treat.

All that being said, they'll change the rules constantly and you'll never be 100% good. Often you'll do everything right, but then get denials because they didn't bother to read your note. Then you'll appeal and they'll deny because you can't request the same procedure that has been denied within the past 60 days.

 

[Ferrismonk]

Opioids depends greatly on your state. In my state, check the PDMP every Rx. UDS frequency based on risk score, risk score calculated from multiple resources, but do a validated screen at least yearly.

Each medication approval depends on the individual insurance's formulary. Sometimes Nucynta goes through without a hitch, sometimes they want you to fail Methadone and Fentanyl before they'll approve Butrans. Best bet is document why you want a particular med and list all the drugs they can't take due to ineffective/allergy/etc.