Wiki Audit (location, Quality, severity)

[Mia12]

So we are going back and forth on this one, Would you considered if a provider documents in the chart notes, and says denies pain, would you count that under the Quality for the HPI for an audit purpose. Then if the says Pt. has a history of neglected, his teeth would you count that under Severity?>
Then we are wondering under the MDM, in a teaching facility Can you count going over the imaging or reviewing the results with the education provider can you count that as 1 point in the MDM in the complexity of data reviewed, there's a debate on that decision.
Thank you for your opinion on this.

 

[dja214]

When counting the descriptors in the HPI you have to remember the elements being used must be supported by the chief complaint.
"Denies pain" and "History of neglected teeth" do not support any descriptors in the HPI. You may consider applying these pertinent positives/negatives to the ROS, if they are infact relevant to today's visit.

Under "Data" you can count that as one of the following BUT not both: Review/order radiology = 1 pt or Review & summarize of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider & documentation of relevant findings = 2 pts

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Teaching-Physicians-Fact-Sheet-ICN006437.pdf

Hope this helps!
Regards,
Deanna

 

[thomas7331]

It's hard to evaluate E&M elements out of the context of the note itself. Generally speaking though, 'denies pain' is an element of a ROS, not HPI, but if it's used in the context of a description of a particular problem (e.g. '...pt presents with a lump on the arm, denies pain') , then I might count it as a quality since it describes the condition under consideration. A history of neglected teeth, however, is not 'severity' - I'm not sure how you could argue that - this is just PFSH. Reviewing imaging results is routinely counted as a point in data, so I'm not sure why there would be a debate on this.

I would recommend against spending too much time debating these kinds of details. Remember that audit guidelines are just that - guidelines and not regulations or hard rules. Unless these are particular things you see frequently in your notes and need to have a firm guideline in place so that your auditors are consistent, it is likely not be worth the investment of time. E&M auditors will count different notes in different ways because there is always an element of judgment involved in assessing E&M levels and there is no way I have ever found to eliminate this. Best practice is to make an informed decision that you can defend and move on to the next one.

 

[Mia12]

Thank you everyone for your input. One of us was giving the point saying they reviewed the image with another provider (so the student,(resident to supervising MD) credit and then the other auditor was not because it was a normal thing that gets done anyways because they were students. Since I was new, I wanted someone else input on the matter. Since I am new on the resident coding part. thank you everyone who has responded. I was giving the point on the MDM side because they were discussing and reviewing the imaging with the supervising MD, so I just wanted to make sure I was correct and I wasn't missing anything, being new it's hard .