1) Regarding your last example about the arm pain, there is no treatment plan from the provider. Is a treatment plan and clinical impression not needed?
I personally would have penalized this particular provider (and I believe I actually did upon audit). Perhaps this wasn’t the best example to share, but the medical decision making component should spell out the determined diagnosis, as well as a plan of care / treatment.
2) If you are billing for the xray, in additional to the E/M, wouldn't it be inappropriate to count the review of the radiology report in the E/M?
Indeed it would. Using the x-ray for the E/M in this setting would be inappropriate.
3)When a patient has Diabetes type II with hyperglycemia and they are having worsened gylcemic control what is the number of points that would be counted for the diagnosis. This patient is an established patient with this provider and this is an established problem. I get a little confused with combination diagnosis codes.
I would give this problem two points for established / worsening.
4) For subsequent inpatient care, how much updated info is minimally necessary to credit the information in the assessment and plan to medical decision making score? For example, if there is no updated documentation to for the chief complaint but there is additional documentation for a condition that is being treated incidentally (did not in any way lead to the admit),.. a chronic rash for instance, would that allow us to use the entirety of the A&P?
Ideally, if a provider is listing diagnoses in the assessment and plan, any diagnosis that does not have a clear plan of continuing care should not be counted for that encounter. I am seeing a pattern where A&P’s are not being updated with clinical impressions on subsequent inpatient visits. If the provider wants anything other than a 99231, the information must be there. Remember that and assessment and plan only counts when there is an actual assessment and plan for an identified condition.
5) Could you clarify what a radiology section is? I have always viewed radiology 70010-79999 as one section and have never given more than one point. Is upper extremity and urinary considered one section? They are both diagnostic?
The radiology section includes every code in the 70000 series. No matter how many radiological examinations are reviewed or ordered in the course of an encounter, this counts as 1 point for category of data.
These questions have been answered by Paul Spencer, CPC, COC relating to his Hands On MDM of the E&M Encounter webinar event from 3/27/18
Post here your questions regarding auditing ,coding, documentation, and compliance. Also, join in on the conversation- help your fellow auditors and compliance professionals in the industry.
1 post • Page 1 of 1