Wiki MCR audit downcoded E/M

[heartyoga]

Medicare requested records as a random audit. The Consult Note as ff:
DOS 1/xx/2021
Reason for Consultation: Severe aortic valve stenosis status post aortic valve replacement surgery
History of Present Illness: Ms ABC is a 60 y.o. Caucasian woman with multiple complex medical problems. She has end stage renal disease and has been on dialysis for about 10 yrs. She has history of severe calcific aortic stenosis, s/p aortic valve replacement using bioprosthetic valve in Dec. 2016 at xx hospital. Two years after her AV replacement surgery, her AV became stenotic again. She also has a history of noncompliance. This was well documented in previous encounters. She said she lives alone. She goes around by electric wheelchair. She has right above knee amputation. She has her daughter help her occasionally. She missed two dialysis sessions recently prior to this admission. She was in severe renal failure w azotemia. She has low BP. She has signs and symptoms of sepsis, severe metabolic acidosis, and mental status changes. Today her mental status has improved, BP also improved. Her BP was low on admission 4 days ago and currently high. Cardiology consult was requested.

Past Med Hx: AV stenosis, s/p AV replacement sx, using bioprosthetic valve at xx hospital. At that time she was told no need for Coronary Bypass and no significant CAD. Hx of COPD. Seizure disorder. Headache. renal failure on hemodialysis 3x/week for about 10 yrs. thyroid problems, HTN, poor circulation, GERD, pscyhiatric problems

Past Sx Hx: Right above knee computation, caesarean section, gastric bypass sx, knee sx, parathyroidectomy. left arm fistula and knee sxs.

Social Hx; Active smoker. No significant alcohol intake, denies drug abuse

Family Hx diabetes prevalent in her family. Grandmother has breast cancer.

Allergies: Tetrcycline, Penicillin, Amoxicillin,Ampicillin.

Medications at home: Zoloft 100 mg qpm, Protonix 40 mg qd, Lopressor 25 mg bid, Keppra 500 mg bid, Gabapentin, Amlodipine 10 mg qd

Reveiw of Systems: Mental status change, hypotension and shock, improving; generalized weakness, fatigue, chronic joint aches and pains, otherwise negative. 12-point review of systems done.

Physical Examination: The pt is currently alert, oriented x 3 and no acute distress. The patients vital signs as ff: BP 138/57, HR 64-70, resp rate 11-14, temp 97.9, O2 sat 98%, Weight 119 kg

HEENT: normocephalic head, aniceric sclera, Neck: Supple, mild JVD, Lungs: Has ronchi, and coarse breath sounds. Heart: S1,S2 loud systolic murmur
Abdomen: normoactive bowel sounds, soft, nontender. Extremeties: Trace edema

Laboratory Tests: Lab tests reviewed carefully. Pls refer to medical records for details. noteworthy to mention is on the day of admission her arterial blood gas showed pH of 7.5, pCO2 57. Her potassium was also high at 6.3 at admission, currently normalized. She is COVID negative. Procacitonin was high on admission 0.7.

Assessment:
1. severe aortic valve stenosis status post aortic valve replacement surgery using bioprosthetic valve in 12/2016 but 2 yrs after that a repeat echo showed deterioration of her bioprosthetic valve to severe stenosis again.
2. ESRD on hemodialysis for 10 yrs
3. Sepsis
4. Hyperkalemia, resolved.
5. Active smoker
6. COPD
7. Hx of non compliance
8. HTn
9. Low BP and shock, resolved

Recommendations:
1. Comprehensive review of the patients meds, lab tests, work up results and history.
2. resume metoprolol 25 mg bid
3. Resume amlodipine
4. Intravenous broad spectrum antibiotic w Cefepime and Vancomycin
5. Patient education
6. the patient is a high risk candidate for a redo aortic valve replacement sx due to presence of multiple risks factors and non compliance issues
7. I will talk to the patient and her daughter about options
8. Patient education
9. Emphasized to the patient the importance of medication compliance and to go to dialysis as scheduled 3x a week
10. I told the patient in no uncertain terms she holds the key to her health and in order to stay healthy she must take her meds as instructed and to go to dialysis and doctors appts as scheduled
11. Called daughter on phone twice but no response.
12. High level complexity medical decision making in the ICU today. Further recommendations will be provided promply based on the patient's clinical progress and work up results.

QUESTION:
1. Medicare came back and recouped $100. Changed 99223 to 99221.
2. Should i appeal?
3. Will appealing/not appealing result in more audits?
4. Anything we could have done better?

This patient is seriously sick and in fact, sadly didn't make it. She had multiple comorbidities.

Thanks for any suggestions/comments.

 

[csperoni]

2) You should appeal if after reviewing, you feel 99221 is inaccurate. Specifically, since this is initial inpatient, you need to meet all 3 requirements of history, exam and MDM. I didn't carefully audit the record provided, but exam seems to fall short of comprehensive, so I would start there. 99222 and 99223 both require comprehensive exam.
3) Were other charts audited with no corrections? If so, whether or not you appeal this should not matter. I personally suggest appealing anything (regardless of dollar amount) where I do not agree with the insurance findings. I think it's less frequent now, but there were times where less reputable companies would just automatically downcode or deny a certain percentage of claims knowing that not everyone would appeal.
4) If after careful review, you agree with the original coding, there is nothing to have done better.
If after careful review, you feel another code is more appropriate, then you should review this with the coder. I mean, no one is 100% accurate all the time, but if someone doesn't know they made a mistake and what the error was, they will keep making it.

 

[heartyoga]

2) You should appeal if after reviewing, you feel 99221 is inaccurate. Specifically, since this is initial inpatient, you need to meet all 3 requirements of history, exam and MDM. I didn't carefully audit the record provided, but exam seems to fall short of comprehensive, so I would start there. 99222 and 99223 both require comprehensive exam.
3) Were other charts audited with no corrections? If so, whether or not you appeal this should not matter. I personally suggest appealing anything (regardless of dollar amount) where I do not agree with the insurance findings. I think it's less frequent now, but there were times where less reputable companies would just automatically downcode or deny a certain percentage of claims knowing that not everyone would appeal.
4) If after careful review, you agree with the original coding, there is nothing to have done better.
If after careful review, you feel another code is more appropriate, then you should review this with the coder. I mean, no one is 100% accurate all the time, but if someone doesn't know they made a mistake and what the error was, they will keep making it.

Thank you !

 

[twizzle]

Neither the history (ROS documentation) nor the exam (insufficient elements) are comprehensive so 99221 is correct which is a shame because the MDM is clearly high complexity.

 

[csperoni]

Neither the history (ROS documentation) nor the exam (insufficient elements) are comprehensive so 99221 is correct which is a shame because the MDM is clearly high complexity.

For ROS, I was always told you could document the pertinent positives and a statement all others negative to count as comprehensive. I would have credited the history comprehensive based on HPI (4+ elements), complete ROS (10+ point) and complete PFMSH. Maybe there's been a change I'm unaware of? Or maybe the exact specific way the ROS is worded is not compliant? Andrew, could you please clarify?
It is really a moot point since the exam is not comprehensive, but would love the input.

 

[twizzle]

A ROS should be a review of systems not points. For example - 'denies chest pain, denies palpitations' would be 2 points but one system reviewed so by saying '12 point ROS done' you don't know which systems and how many were reviewed. Had they said which 12 systems were reviewed then I would give credit for 12 systems. It's all too vague.
Some of this info is MAC-specific however but I think as a ROS this documentation is not acceptable. The phrase 'with the exception of the pertinent positives and negatives, all other ROS are negative' or something similar is the way we encourage providers to document if they want credit towards a comprehensive history.