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E & M question - Medical Decision making

  1. Default E & M question - Medical Decision making
    Exam Training Packages
    Hello: I have a couple of questions I hope someone will help me with.

    I do know this answer but I think I just want reassurance.

    The doctor does a in pt consut, it is a complete HPI and ROS and the Medical Decision making is complex, pt does need a AVR & CABG. Then physicial exam Detailed; 12 bullets for 1997 or 6 organ systems for 1995, this would be a 99221!?

    Under his recommendation he states; had a long discussion with pt will schedule surgery etc etc; He does not document the time he spent.

    He always codes the 99223 or leve 5 consult..I have explained what needs to be dicated in the report explained elements etc but he never seems to dictate a comprehensive physical I have to change it to 99221, right! I just hate doing that.

    He tells me my patients have high morbitiy and complex most often. I know he does spend alot of time with them but he never documents time spent. He does Cardiac & Vascular surgery cases and I know he puts alot of work in what he does but he just does not document.

    I told him he deserves to recieve the compensation for the work he does but it has to meet the Medicare guidelines, but he does not understand or just does not feel it is that important...I have given him handouts etc but......

    Any suggestions

    Also does anyone have an 1997 audit template they would be willing to share with me? I have a good 1995 but I can not find a good copy of 1997 just would like a better copy.

    Any ideas would be greatly appreciated. I did recommend an outside auditor but have not heard anyting yet.

    Thanks in Advance!!

  2. #2
    Sorry, but without a comprehensive exam documented, the best you can do is 99221. He's got to document the work to get paid for it - "not documented, not done."

    I use Trailblazer's E/M audit tool - you can find a copy of it here:

    I also made a spreadsheet in Microsoft Excel, and pasted all of the multi-system exam elements into it, so I can just go through and check them off. (We only use 97 rules.) I think that showing the doctors exactly what they got credit for, and (more importantly) what they didn't get credit for, helps to communicate why the code that I'm coming up with is correct. That's just my 2 cents, though...

    Good luck!

  3. #3
    Milwaukee WI
    Default Medicare vs commercial
    I think your doctor is stuck in thinking about consultation codes ... where his documentation of a detailed exam (along with his history and exam) would equal a Level 3 inpatient consultation.

    If your patient is NOT covered by Medicare, AND the insurance carrier still accepts the consultation codes, you could code 99253.

    I share your frustration. A friend codes for a surgeon who will NOT document his visits much beyond a brief HPI, brief exam and plan for surgery. (e.g. pt referred for evaluation of mole on forehead, noted by PCP on annual exam. Alert & cooperative. I note a 3 mm lesion suspicious for melanoma, 1 cm above rt eyebrow. Will excise as soon as can be scheduled.) His response to pleas for more documentation was that he gets paid for the surgery and just doesn't want to waste more time on documenting to satisfy some arbitrary standard. So he gets a level 2 new patient visit over and over again.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  4. Default
    Here is a 1997 and 1995 audit form from The Coding Center. Hope this helps.

  5. Default
    Thank you all for your help and the forms from the Coding Center will be helpful.. I do appreciate it

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