JParker5
Networker
Hi.. I need a little help.
We have an outside vendor who codes are ED visits and when I audit the notes, at times I get a different level then they do. I see a majority of the time it's between a level 3 and 4. The physician usually have a Comprehensive History and Exam so it fall on the MDM.
One example I have is the patient comes in with vomiting and diarrhea. No workup and was diagnosis w/gastroentrisis. I would code the visit as a level 3 because there wasn't much MDM to the visit but the vendor coder would code it as 4. The physician didn't need to complete a full exam. The same for a fracture visit.
Any thoughts????
We have an outside vendor who codes are ED visits and when I audit the notes, at times I get a different level then they do. I see a majority of the time it's between a level 3 and 4. The physician usually have a Comprehensive History and Exam so it fall on the MDM.
One example I have is the patient comes in with vomiting and diarrhea. No workup and was diagnosis w/gastroentrisis. I would code the visit as a level 3 because there wasn't much MDM to the visit but the vendor coder would code it as 4. The physician didn't need to complete a full exam. The same for a fracture visit.
Any thoughts????