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Editor's E-Note
As AI continues to advance, its time-saving potential has captured the imagination of people from all walks of life. One example can be found in health care, where the ability to automate tasks and save time is becoming an imperative. For evidence, look no further than the FDA, which recently announced an aggressive timeline for incorporating AI into its review process. FDA Commissioner Martin A. Makary, MD, MPH, believes this will allow the agency to drastically speed up scientific reviews. For more details, check out this month’s exclusive.
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— Dave Yeager, editor |
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FDA Announces AI Rollout Timeline
In a historic first for the agency, FDA Commissioner Martin A. Makary, MD, MPH, announced an aggressive timeline to scale use of AI internally across all FDA centers by June 30, 2025, following the completion of a new generative AI pilot for scientific reviewers.
“I was blown away by the success of our first AI-assisted scientific review pilot. We need to value our scientists’ time and reduce the amount of nonproductive busywork that has historically consumed much of the review process. The agencywide deployment of these capabilities holds tremendous promise in accelerating the review time for new therapies,” Makary says.
The generative AI tools allow FDA scientists and subject-matter experts to spend less time on tedious, repetitive tasks that often slow down the review process.
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HHS Updates Regulatory Guides for Safe Use of EHRs
According to Healthcare IT News, the assistant secretary for technology policy has released an update to the guidance documents health care organizations use to assess the safety of EHR systems. The new Safety Assurance Factors for EHR Resilience Guides have revisions to the 21st Century CURES Act, including AI use guides, cybersecurity, and integration of FDA-approved medical device data into EHRs.
Investing in AI and Automation Is a 2025 RCM Priority
Investing in AI and automation in 2025 is a priority, says AAPC. AI makes revenue cycle management more efficient, improving the accuracy of claims, streamlining workflows, and enhancing an organization’s financial performance.
HHS Layoffs Could Imperil Medical Device Cybersecurity
A House of Representatives meeting scheduled to analyze cybersecurity threats in medical devices comes in the middle of massive Health and Human Services and FDA layoffs, says Medtech Drive. |
Have a coding or documentation question? Get an expert answer by sending an email to edit@gvpub.com.
This month’s selection:
Let’s say a hospitalist does a face-to-face encounter and medically clears a patient for discharge on February 1. The patient is held over for three days awaiting a bed in a skilled nursing facility and physically leaves the facility on February 4. The hospitalist continues to see the patient until the 4th. What would be the proper way to code/bill for these services?
Scenario 1:
2/1 – 99238/9
2/2 – 99231
2/3 – 99231 (diagnostics are ordered/reviewed, patient given antibiotics)
2/4 – 99231
Scenario 2:
2/1 – 99238/9
2/2 – No billable charge based on medical necessity
2/3 – No billable charge based on medical necessity
2/4 – No billable charge based on medical necessity
Scenario 3:
2/1 – 99238/9
2/2 – No billable charge based on medical necessity
2/3 – 99232 (patient spikes a low-grade fever w/abd pain)
2/4 – No billable charge based on medical necessity
Are any of the following four scenarios billable under the teaching physician’s (TP) National Provider Identifier with the -GC modifier?
- Resident and TP see the patient together. The resident completes the note, and the TP adds a macro statement, “I was personally present with the resident for the critical portions of the exam and medical decision making. I reviewed the documentation and agree with the resident’s plan of care.” The TP then electronically signs the note.
- Same scenario as above, but the TP adds an addendum stating, “While examining the patient, they expressed a tingling sensation in both upper ext as well as neck pain. Based on my review of the CT scan completed earlier today, I will continue to hold the patient’s home meds. Spoke with Dr. A, Cardiologist, and she agreed to hold home meds. She will see the patient at some point today during her rounds. Placed order for cardiology and neurology consults.”
- Resident sees the patient and completes the progress note. Later that same day, the TP has a face-to-face encounter with the patient and documents his own progress note, incorporating the resident’s note into his. The TP clearly documents his own A/P and adds a macro statement, “I have seen the patient independently and discussed the case with the resident.” TP electronically signs and dates the note.
- Resident sees the patient and completes the progress note. He and the TP collaborate the following day and discuss the case. The TP adds a macro statement, “I reviewed the resident’s documentation and agree with the plan of care,” and the TP electronically signs and dates the note.
Deanna Anderson, CPC, CPMA, CEMC
Remote LRHPG Internal Profee E/M Auditor
LRH Physician Group Coding Department
Lakeland, Florida
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