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Need advice, please

  1. #1
    Phoenix, AZ
    Default Need advice, please
    Medical Coding Books
    I'm new to this practice and am having a very difficult time with my specialist (cardiology). They insist on adding all the cardiology dx codes to the MDM whether or not they are treating them at the time. When approached, I'm told that they have to consider all of these diagnoses for proper treatment. I guess I can see that if the patient comes in with an acute problem and they are admitted. However, I have a HUGE problem when the patient comes in for a 6 month or 1 year f/u appointment and there is no problem or complaint.

    Does anyone have advice on how to best approach this very touchy subject? Some of my docs have been in practice for 15 to 20+ years.

    Thanks in advance,
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  2. #2
    Based on the limited information you have given I am leaning towards the doctors point of view on this one. Just because they are not currently having "problems" doesn't mean the problem went away and is not being treated. These would only count as 1 dx point each for established stable.

    If they are coming in for follow-up with a cardiologist, something is not right or at risk of becoming not right so they are managing these issues. It doesn't sound to me like they are padding their documentation which is what I get the impression you feel they are doing.

    Just because you have 4 or more dx points for a recheck with no current complaints doesn't give you a higher level. You still have to have the history or exam and risk to get your level.

    That is not to say they aren't padding documentation, I am just basing this answer on what you have posted and nothing was mentioned about history or exam being questionable.

    Just my opinion,

    Laura, CPC, CEMC

  3. #3
    Phoenix, AZ
    Hi Laura,

    I think I worded my earlier message incorrectly. I think they are padding their documentation. For instance, I will give credit for hyperlipidemia and diabetes (cardiac risk factors and managed by the PCP) if my doc actually looked at lab work or changed meds. Or if my doc states that the patient is having a problem exacerbated by DM or hyperlipidemia.

    However, if the patient comes in for a 1 year f/u for a fib with no complaints and my doc adds a fib- continue current medical therapy with no changes, old MI (from several years ago), S/P PTCA (from 2-3 years ago), hyperlipidemia-no changes or lab work and managed by PCP, DM- no changes or lab work and managed by PCP.

    Patient is performing all ADLs without problem and has had no hospitalizations or complaints in the last year. He comes in for med refills. My doc documents a exp prob foc hx, comp exam with the above dx codes and plans.

    I'm thinking this is a 99213. My doc wants a 99214.
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  4. #4
    In that case I would have to say it looks like they are padding documentation. A comphrensive exam seems a bit much, I can't get mine to document those on new patients with major problems!

    While I really don't have a problem with them getting moderate MDM, RX management (even if they don't change it they are still taking the risk by giving it) and 3 stable chronics (they do have to take them into consideration), I do have a problem with the exam part of it. Where is the medical necessity for it? I'm not clinical but it seems a bit much considering the presenting problem.

    Do you have any providers that are compliance driven who understand coding? I think this may need to be approached from a peer to peer review angle if you truly feel this is an issue of padding for higher levels.

    On the other hand the status of 3 chronic conditions, 2 ROS, and 1 element of PFSH would get you the detailed history which in my opinion would be appropriate to support the 99214 with that mdm.

    Good luck,

    Laura, CPC, CEMC

  5. #5
    Phoenix, AZ
    Thank you!! I so needed another point of view. They get the comp exam from EMR!!! I'm trying to get them to change their habits. So far, I'm not having any success. I do have a new provider who has GREAT coding skills. He does not use the comp exam when an exp prob or detailed exam will do. However, he's really new (two weeks with the practice) and I'm not sure how he would feel about peer to peer review. I'll see what he has to say.

    Thanks again!!!
    Cyndi Allen, CPC, CIRCC
    2015 Local Chapter President, Casa Grande, AZ

  6. #6
    Hi -
    If they are copying their exam from the EMR without any sort of reviewing and making it pertinent to that visit you definitely want to alert them that this could be considered fraud/abuse by Medicare. There was an article in the September 2006 Medicare Part B Resource Newsletter by NHIC, see link. Go to page 100 for the article.
    Other than that, I agree that some diagnoses - even if they are old - may have a place in the MDM. It just depends on the individual case, but to just note them in an attempt to inflate the code is inappropriate.
    Karolina, CPC, CPMA, CEMC

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