Wiki MDM advice

[dsmith06351]

I have been reviewing office notes for the doctors that I work for, and I am looking for some advice on the MDM portion. If I follow the coding guidelines a patient comes in with conjuctivitis, it is a new problem for this physician with no work up and the MD prescibes an antibiotioc it is a moderate level of MDM. The physician also does a detailed hpi and a detailed exam, I now have a 99214. The physicians that I work for are worried that this is overcoded because of the dx of conjuctivitis, when and how do I decide that the dx does not warrant the level of coding.

Thanks for any advice

Denise Smith CPC-A, CEMC

 

[FTessaBartels]

YOU don't

The answer is YOU don't. The physicians perform the services they deem medically necessary to treat the presenting problem, and document what they do; YOU translate that documentation into a code.

It is what it is.

That being said, their concern about this, however, makes me wonder if you are using an EMR/EHR that automatically populates the visit documentation with that detailed history from a previous visit, and prompts the physician to document a detailed exam. If so, your physicians are right to be concerned.

What you need is a protocol in your office regarding when it is appropriate for the physician to override the audit tool to lower the level of service to what the physician deems appropriate for the presenting problem.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[jcdavis2007]

I am having the same problem with one provider. He does and expanded problem history, but a detailed exam on every patient he see. If it is URI, ear infection, bronchitis, strept.....no matter what it is a detailed exam and he always writes a script.....how do I know if this is acute illness 99213 of new problem 99214?