Compliance and Provider Documentation

Consider this scenario:

Dr. Klein recently saw Terry McGwin in the office for complaints of fatigue and trouble sleeping. The patent is 68 years old and is the father of Dr. Klein’s lawyer. Dr. Klein documented the following History of Present Illness:

“Terry comes in today because he has not been sleeping well and is more tired than usual. He reports that this started around his birthday, little over two weeks ago.”

He also documented a medical exam, review of systems and ordered two lab tests — a BUN and PSA.

You are a coder and recently completed your 60-day training period. As you complete the above account, you note that the PSA does not clear edits because of medical necessity. The charge for the PSA is $105.

You query Dr. Klein and inquire if there is missing or incomplete documentation. Dr. Klein calls you on the phone and presses you for information. He explains that he is wrapping up for spring break and wants all accounts finished up today. You explain that the PSA is not covered because the documentation provided does not meet medical necessity. Dr. Klein tells you to record “family history of prostate cancer” in the chart and hangs up.

Keep in mind Title XVIII of the Social Security Act, section 1833 (e), which prohibits Medicare payment for any claim which lacks the necessary information to process the claim, then post to the discussion regarding the following:

1. How do you follow up on the above scenario – what steps do you take? Consider what you need to complete and code the account, and who might offer guidance to you on this scenario.
2. Indicate if this is a compliance issue and why you think it is or isn’t.