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Auditing a Specialist

  1. #1
    Location
    Kansas City, MO
    Posts
    431
    Default Auditing a Specialist
    Medical Coding Books
    I occasionally have to audit visits done by a Rhematologist...a specialty I am not familiar with. This doc tends to favor level 5's and I am just not seeing it. He does have his complete/comprehensive HX and EXAM...but when it comes to the MDM I am not sure.

    In the table of risk, it does list under the HIGH risk section "severe rheumatoid arthritis" as an acute illness...and it also lists "drug therapy requiring intensive monitoring for toxicity"

    His diagnosis is almost always:
    1. Rheumatoid arthritis
    2. High-risk medication monitoring


    The disease certainly doesn't sound fun, but from his notes I rarely get the impression that it is "acute" or "severe". I admittedly don't know a lot about it though...is it always high risk, or can it be in a controlled low-risk state?
    Not so sure about the high risk medication....as the note usually ends with "see pt back in 6 weeks".
    Seems like if things were so high risk he'd be seeing them sooner.

    This dr is not readily available to me...And so if I do have to approach him, I'd like to not sound like an idiot.

    THOUGHTS?? PLEASE??

  2. #2
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    Does the provider list which medications the patient is on for the RA? I know some disagree; but if on methotrexate, gold injections, Humira, or most of the RA meds, these are highly toxic to the liver and require periodic blood work to check liver function; I count that as high on the table of risk if addressed in the documentation. Six weeks is about right - most of our rheumatologists monitor at least that often until the patient is stabilized on the meds; they do blood work every three months even when it seems they're fairly stable, as they can seem to be doing quite well then all of a sudden the blood work comes back abnormal. They might not see them every three months, but do get them in right away if there are abnormal results. In addition, since RA is an autoimmune disorder, patients are more susceptible to infections, etc.

    When we first got this specialty, I audited them closely for quite a while, because I thought they were billing/coding high - but after reviewing, most were level 4 based on all elements and very good documentation.

    I hope this helps!
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  3. #3
    Default I agree
    Hello ladies,

    I agree with Cindy. It is important to check the documentation and possibly look for treatment response in notes for the medicine prescribed and what the management involves. Methotrexate is serious business (it inhibits the metabolism of folic acid) and can really mess up the liver after prolonged use. A friend of mine has RA and I just recently completed a project on RA. Become familiar with the type of treatment for RA.

    Good Luck,

    Quote Originally Posted by LINDALOUV View Post
    I occasionally have to audit visits done by a Rhematologist...a specialty I am not familiar with. This doc tends to favor level 5's and I am just not seeing it. He does have his complete/comprehensive HX and EXAM...but when it comes to the MDM I am not sure.

    In the table of risk, it does list under the HIGH risk section "severe rheumatoid arthritis" as an acute illness...and it also lists "drug therapy requiring intensive monitoring for toxicity"

    His diagnosis is almost always:
    1. Rheumatoid arthritis
    2. High-risk medication monitoring


    The disease certainly doesn't sound fun, but from his notes I rarely get the impression that it is "acute" or "severe". I admittedly don't know a lot about it though...is it always high risk, or can it be in a controlled low-risk state?
    Not so sure about the high risk medication....as the note usually ends with "see pt back in 6 weeks".
    Seems like if things were so high risk he'd be seeing them sooner.

    This dr is not readily available to me...And so if I do have to approach him, I'd like to not sound like an idiot.

    THOUGHTS?? PLEASE??
    Last edited by KellyLR; 08-01-2010 at 04:34 PM. Reason: Speling
    KL
    CCS, RHIT, CPC, CMBS

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