Auditing Medical Decision Making

adri3421

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Does anyone know of a good resource with more clinical examples for the table of risk?

Medicare's table of risk is so generic and broad I would love to find something where someone has categorized some additional diagnoses & treatment options.

My doctors really want more guidance on the medical decision making component and its really difficult for me to help them b/c I am not a nurse & do not have a strong clinical background. They work trauma and what I might think is an acute complicated illness, they consider to be high complexity.

For example: pt comes in with 1st degree flash burns to face & mild respiratory distress. To me this is an acute complicated illness. My doctor says it is high risk b/c the patient is at high risk of developing esophageal burns during the first few hours after the injury and will require pulmonary toilet.

It makes it very difficult to audit their E/Ms. I just wish I could find some additional resources out there in addition to the table of risk.
 
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If they think patient at high risk they should SAY so

If they think a patient is at high risk, then they should SAY so. Remind them that most auditors are NOT physicians / clinicians. We cannot assume what they are thinking. If they believe a patient is at high risk for a life threatening complication, they should say so.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

adri3421

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RE: Auditing MDM

My email is aplummer@mc.utmck.edu

Any information you have would be wonderful. It is a hard thing to argue MDM with a physician when you are not a clinician. I really appreciate your responses.
 

Annette

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Tessa said it best

Tessa is right in that the physicians should document why they believe it is a high risk case. In the abscense of labs, imaging, record review, etc., documentation should include a physician's differential diagnosis to support their higher level of decision making or high risk that is not apparent in the note.

If they think a patient is at high risk, then they should SAY so. Remind them that most auditors are NOT physicians / clinicians. We cannot assume what they are thinking. If they believe a patient is at high risk for a life threatening complication, they should say so.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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Janet, If it's not too late to jump on the bandwagon, would you mail me one of those too?
I've thus far been unable to convince my Physicians that they need more documentation that 'MDM = Moderate' .
Thanks in advance!
Robert.wehner2@mercy.net
 

hmagao

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Questions

Can anyone tell me when the exam is audited, is it body area OR organ system, or is it body area AND organ system? Also, is a referral out to another physician considered additional work-up? :confused:

Any help is appreciated.
 

hawkinsj

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Janet

I have had SOOOO many requests for help with medical decision making. This question string was from awhile ago so nice to see people using the strings to get help. I decided to get a better answer out to all others, not that I don't want anymore requests, just thought if so many are asking for help there might be others.

Okay, first, I am working on getting the table of risk created with wording that matches our practice. Since we admit and round only in hospitals we needed options that were related to hospital work. The DX and treatment on the original table was trying to cover too many bases. I met with my Director of Compliance, and I am hopeful we can work this up together. I suggest for your practice you do the same. Create the same template you find on the audit worksheets for risk and then using the original table with the examples, create one together that fits your practice.

Medical necessity drives decision making. You can't decide treatment until you are clear on what is necessary. Like you can't bake cookies until you know what you need to do that. I highly recommend the book Auditing Physician Services by Betsy Nicoletti. It is my go to book for every question I ever have. Your providers should purchase this for the practice I can't imagine being without it. I also have a really nice audit worksheet that is in color, and very clear. It has a logo on it for First Coast Service Options and also has CMS logo too. Wish I could remember where I found it!! Your worksheets are the tool that will get you proficient at auditing. Use them every time you review or audit a document. Use them until you can teach them to someone else!

So, first off, you must understand medical necessity yourself. Once you get it, and it took me awhile, then MDM begins to click. The necessity drives the decision making. If there isn't much work necessary or very many orders necessary then your decision making will probably be a lower code.

From there we utilized audit examples of our providers work. In meeting with our docs it really helps if they have their own work or work that is pertinent to our practice to look at. I took the documents, a red pen and wrote the descriptors, the exam and circled the items for MDM. We use the '95 guidelines so ALL the teaching is geared to that, down to the signature. We also created a series of questions for the H&P, DCS, progress note and critical care note so they could self audit and then review with the Compliance director. This is very effective.

It is good to show them the guidelines and show a perfect note and a REALLY bad note as compared to these guidelines. BUT it is what makes for an optimal note and billing.

For our type of work, data points can be really hard to get every day when figuring out MDM. So, while I always try to look for those and teach them how to note them, I find that focusing on the education of reflecting high risk and correctly documenting your DX carries more weight for a high risk document. If you have a high risk patient then everything you do should show that risk If you don't have a high risk patient based on necessity then review and choose an alternate code.

I hope this stuff helps you out. Get creative, buy some books, keep talking to coders!!
 

truerina

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Janet,
Would you be kind enough to share this information with me as well?
I would really appreciate it.
Thanks you so much
 

rthames052006

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If they think a patient is at high risk, then they should SAY so. Remind them that most auditors are NOT physicians / clinicians. We cannot assume what they are thinking. If they believe a patient is at high risk for a life threatening complication, they should say so.

Hope that helps.

F Tessa Bartels, CPC, CEMC

Tessa is correct! We non-clinical coders need to educate our providers on documenting their MDM in a way that we can follow and distinguish it.

Whenever I do an educational session with my providers I stress this point to them that it's not only their fellow doctors and mid levels reading their notes but auditors and coders as well. The better they document the easier it is to follow their thought process.
 
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