maine4me
Guru
I am currently working with our general surgery group to implement the EMR. I am reviewing some notes to insure that the doctor has capture all the components required for documentation of the E/M service. What I have found is that he is not only capturing everything there is more than what I would deem necessary.
Since these patient's are seeing him for a specific problem does it seem unreasonable for him to have a complete exam ('95 Guidelines) and more for each patient. In my mind this is could be a red flag. With that said, I am cautiously approaching him to streamline is documentation process, because I don't want to end up with very little documentation.
Here is an example:
Patient presents to office with a cyst on his left shoulder. He is a new patient. History codes out to EPF, since the HPI is brief. The exam however is comprehensive with 13 systems documented in depth. In my opinion many of the areas examined were unnecessary, but I am not sure how other auditors would view this. The MDM was moderate. Incision and drainage was planned for a future date.
I in no way want to question his clinical judgement, but I also do not want his overly extensive notes to come into question in an outside audit. Now is the time to refine his documentation.
Since these patient's are seeing him for a specific problem does it seem unreasonable for him to have a complete exam ('95 Guidelines) and more for each patient. In my mind this is could be a red flag. With that said, I am cautiously approaching him to streamline is documentation process, because I don't want to end up with very little documentation.
Here is an example:
Patient presents to office with a cyst on his left shoulder. He is a new patient. History codes out to EPF, since the HPI is brief. The exam however is comprehensive with 13 systems documented in depth. In my opinion many of the areas examined were unnecessary, but I am not sure how other auditors would view this. The MDM was moderate. Incision and drainage was planned for a future date.
I in no way want to question his clinical judgement, but I also do not want his overly extensive notes to come into question in an outside audit. Now is the time to refine his documentation.