My situation is similar but the docs are billing (almost routinely) a Level IV or V along with a preventive visit. I'm having diff auditing this to justify both a preventive and a high level problem oriented. There are mulitple (8-10) diagnosis and they are addressed extensively. Is this a red flag? Do you have any suggestions for guidance on auditing these E/M's?
Thanks,
Deb
Anytime there's an abundance if high level E/M's, it can be a red flag - even if they're justified. Payers tend to notice doctors that cost them more money. Since the history and exam elements are largely duplicated in this situation, the problem E/M level should be primarily based on the MDM involved. Just because the patient has several established diagnoses, like hypertension or diabetes, addressing them during a preventive visit doesn't necessarily warrant billing a separate code. New problems, or a change in the severity of existing problems that requires a re-evaluation of current treatments, are both good examples of when using a problem E/M is acceptable. If you're unsure, review the notes and really consider:
Was this problem something that the doctor had to investigate at all, or was he already aware of the current status and how to successfully manage it for this patient? Did he have to order tests? Make a significant change in a treatment approach?
And for new/worsening problems, what are the potential consequences involved with having this condition? Will invasive testing be necessary? How much risk is associated with treating it?
You should advise providers to bulk up their impression, plan, and observations about abnormalities encountered in their notes to really paint the picture of how much mental work was required to gain an accurate assessment of the patient's condition. particularly when they're reporting codes that have a higher probability of triggering an audit. The motto of "Not documented, not done" can be just as easily applied to the abstract MDM element. Except it's more like "Not documented, not difficult/complex". If they want credit for using their expertise to address a problem, then they have to show that they put that vastly-knowledgable doctor-brain to work. Leaving insignificant notes allows room for an auditor to assume that the problem was insignificant, and that is not an assumption that will benefit the doctor in any way,
