I too had these concerns for a long time. When I first started in the medical field I was in a small office with paper charts and transcribed notes where the average visit was a 99212 or 99213. Now I am working in a large office with many physicians, PA's, and Nurse Practitioners and the average visit is a 99214. When I first started at my current office that made me very nervous. However, now I find our EHR as a very comprehensive tool. We are an Internal Medicine/ Walk-in Clinic so many of our patients come in with acute illness. For established patients a new problem with no additional work-up planned and Rx management would indicate a MDM of moderate complexity. The part where I feel that EHR really helps is the exam according to CMS 1997 guidelines a detailed exam only needs 12 points in at least 2 body areas. These points are easier to accumulate on an EHR because you have the options in front of you during the visit while when usuing transcription typically at the end of the day with limited notes the most that was recorded on a usual basis were areas with problems. This is not only beneficial to coders but if there is more unusual behavior of an illness it is nice to know the other systems were addressed and normal in previous notes. With the MDM and Ex both moderate that would make an established visit a 99214. As far as Hx I would go ahead and have the providers notate the ROS and PFSH. These are things that are commonly addressed in notes but the providers don't even think about it like when they Rx something like Cipro instead of Amoxicillin due to allergies.
However, I must advise to still be careful and check on payers. Many payers do not accept coding over MDM so if you have a visit with a comprehensive history and exam but a low MDM the payer would want a 99213.
I hope this is what you were looking for. The best thing is provider education. We don't want to see one note that says the abdomen was nontender then another the next week with a CC of abdomen tender for over a month (that wouldn't be pretty to an auditor trust me I've seen in doing an external audit for someone).
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