# Medical Decision Making - risk component



## ARCPC9491 (Aug 13, 2008)

I have read tons of the postings on here regarding E/M...one of the obvious things I see is regarding Medical Decision Making and the risk component.

Just because you have a "new problem" and a "prescription" doesn't necessarily mean the overrall Medical Decision Making is of Moderate....which as we know correlates to a level 4 (given the history, exam are sufficient for the type of E/M)

For example, I've seen a ton of notes where people are giving level 4's for pharyngitis or otitis media just because it's a new problem and they gave a prescription. Most providers would agree that for these problems, the Medical Decision Making is of Low Complexity. It is commonly routine to give prescriptions for these types of conditions. 

Even though "the table and points system" gives you a Moderate Decision Making, doesn't mean it's a level 4. No tables or points can justify medical necessity - which of course is the number #1 key component of all.

So next time you see a patient for a minor condition that requires a prescription.....re-evaluate your decision to go with Moderate decision making.... I believe most people would agree you are overcoding.


----------



## dmaec (Aug 13, 2008)

ARCPC9491 said:


> I have read tons of the postings on here regarding E/M...one of the obvious things I see is regarding Medical Decision Making and the risk component.
> 
> Just because you have a "new problem" and a "prescription" doesn't necessarily mean the overrall Medical Decision Making is of Moderate....which as we know correlates to a level 4 (given the history, exam are sufficient for the type of E/M)
> 
> ...



I have to respectfully disagree with your comment.  It is what it is.  New problem DOES get a 3 - (4 if there's work-up planned),labs are usually done, sometimes xrays - and a prescription given DOES give it a higher Risk Factor.  That being said - MDM "alone" does not determine "medical necessity"... Often the MDM is MOD - and the HPI and EXAM are PF - which of course brings the E/M level down (not level 4).  
The determination of the E/M level is based on the components of each element.  High or low levels for pharyngitis or otitis depending on what documentation supports. (the combination of the HPI/EXAM/MDM).  
So, just because it's "only" pharyngitis or otitis - doesn't mean it doesn't support a level 4.
_{that's my opinion on the posted matter}_


----------



## HCCCoder (Aug 13, 2008)

I totally agree with Donna,
Thank you!


----------



## smwermter (Aug 13, 2008)

I also agree 100% with Donna!


----------



## ARCPC9491 (Aug 13, 2008)

I guess I'm a little confused by your response, Donna.

Medical Necessity is first and foremost the #1 factor any ANY service rendered by a physician - regardless of how well documented _anything _is. 

A physician could document a complete hx, ex, and take mdm to the max on every patient, but is that really necessary? I think not.

Any medicare manual will advise against this as it is not deemed medically necessary.

So you're telling me, you would do a comprehensive history and comprehensive exam on a patient who has a self limited/minor problem such as otitis media or pharyngitis? (with the reference to new level 4) I beg to differ. 

I understand that the tables states if you have a new problem with a rx it is a moderate level of mdm...however...mdm cannot be truly determined without the clinical judgement of the provider...thats why EMR's and coders who do not have the skill and knowledge of the MD, interpret things in different ways...thus producing different results....

I guess what I'm trying to say is most of these simple/minor problem patients are coded as level 4's when rather they should be 3's.


----------



## Lisa Bledsoe (Aug 13, 2008)

ARCPC9491 said:


> I guess I'm a little confused by your response, Donna.
> 
> Medical Necessity is first and foremost the #1 factor any ANY service rendered by a physician - regardless of how well documented _anything _is.
> 
> ...



I agree with Donna - and I did not see anything in her comment that she would condone a comprehensive history and exam on a patient with a self limited or minor problem.  Documentation must support the level of service AND must be medically necessary.  In the pharyngitis example, the "clinical judgement of the provider" could be to prescribe medication or just OTC treatment.  The risk in giving an RX is substantially greater than just telling the patient to take ibuprofen.  So yes, if you do not prescribe medication in this scenario you most likely are looking at a 99213 because you _probably_ have a detailed history, EPF (or even just PF) exam, and low MDM.  BUT if the provider prescribes medication, the MDM does become moderate based on the *RISK* involved - so if you have a detailed history, and a simple PF exam, but Moderate MDM - you are looking at 99214.  *It's all in the documentation and the medical necessity.  *


----------



## dmaec (Aug 13, 2008)

ARCPC9491 said:


> I guess I'm a little confused by your response, Donna.
> 
> Medical Necessity is first and foremost the #1 factor any ANY service rendered by a physician - regardless of how well documented _anything _is.
> 
> ...



to clarify, I didn't say that medical necessity wasn't a factor in the service provided by the physician - that's obvious (it's why the patient is coming in, for medical treatment of some sort) - *what I said was: "MDM "alone" does not determine "medical necessity".*
*that being said (again) **...* I'm not saying I'd do a comprehensive history and comprehensive exam on a patient who has a self limited/minor problem such as otitis media or pharyngitis,*I* wouldn't do a comprehensive anything (the provider would). So if my physician documents a history and exam that is pertinant to the reason the patient is in - and it meets the components in each element, making it detailed or comprehensive  then YES - if it supports the level 4 that's what I would code it out to....yes (again)  
To go further, just because a provider documents 3 pages does not mean it's an automatic high level E/M. same/same for short documentation - it doesn't automatically mean it's a low level - it all depends on what the documentation supports.
As for determining MDM - the clinical judgement of the provider is "IN" the documentation (or should be), which is how we (coders) decide presenting problem, dx procedures ordered and management options selected, that help determine the level of MDM.
I would agree that more often than not these simple issue are lower level E/Ms.  As I said before - usually, the MDM is high and the HPI and EXAM are lower...equaling out to lower lever E/M "Often the MDM is MOD - and the HPI and EXAM are PF - which of course brings the E/M level down (not level 4)"
respectfully - 
_{still, my opinion on the posted matter}_


----------



## dmaec (Aug 13, 2008)

I agree with Lisa: simply said 
*"It's all in the documentation and the medical necessity." *
_{again, my opinion}_


----------



## ARCPC9491 (Aug 13, 2008)

I've always had a hard time explaining my thoughts.....  LOL

Ok, you have a patient (new or established) with a minor/self limited problem (patient presenting for the first time w/ this problem - not stable, improving, or worsening)  Would you give credit for "self limited/minor problem" or "new problem, no work up" 

In order to come up with moderate mdm (based on problem and risk only - no data) you would have to atleast be using new problem and moderate risk which of course equals Moderate overall mdm. This is where I feel the misconception lies. 

Because - if no one were giving credit for a "self limited/minor" problem, why would they even have it on the mdm tables? thus, resulting in overcoding by using new problem, no work up planned. because if self limited/minor would be used...the overrall mdm would be of straightforward/minimal complexity... (with your rx for for mod risk) thus justifying my opinion that these types of conditions warrant lower level e/m's.
(this all based upon the fact of course the other components are met)


----------



## tefranklin57 (Aug 13, 2008)

You code your E/M by how well the doctor documents, not by the diagnosis.
I agree it doesn't seem right, I'll have a COPD be a level 3 and ear ache become a level 4.  It's all in the doctors documentation.


----------



## HCCCoder (Aug 14, 2008)

In my opinion, self-limited problem is the one that can go away by itself, without treating or with minimal short-time treatment.
In this case, for pharyngitis, Doctor rx'd medication, meaning, that It is not something that will go away by itself. By that said, the condition qualifies for 3 points (new problem) and since medication was prescribed, the risk is Moderate. 
The other thing is that, the level of service does not only come from MDM. 
I understand, that the MDM is the most important part of the LOS. The MDM can be SF, but if Doctor documented Detailed hx and Detailed PE then the overall LOS would be 99214, regardless of SF MDM. 

Lilit


----------



## Lisa Bledsoe (Aug 14, 2008)

Per CMS, MDM must be one of the two components met to determine level of service.  Therefore a SF MDM with detailed hx and exam = 99212.


----------



## Lisa Bledsoe (Aug 14, 2008)

ARCPC9491 said:


> I've always had a hard time explaining my thoughts.....  LOL
> 
> Ok, you have a patient (new or established) with a minor/self limited problem (patient presenting for the first time w/ this problem - not stable, improving, or worsening)  Would you give credit for "self limited/minor problem" or "new problem, no work up"
> 
> ...



Under # of dx's and tx options, it states "self limited or minor (stable, improved, or worsening)" which indicates it is a follow up to a previous visit...if it's the first time the provider is seeing the patient for the problem, it is "new" to the provider...


----------



## ARCPC9491 (Aug 14, 2008)

I respectfully disagree with the posting that said self limited/minor conditions should not require prescriptions and should go away on their own w/o rx management... because if you look in the table of risk the examples they give for self limited are problems like colds, insect bites, tinea corposis.....colds receive rx's, as do insect bites, and ring worm, which also is treated by rx's.


Problem Points

Self Limited/Minor ............................ 1 point
Est. prob........stable or improving........1 point
Est. prob........worsening....................2 points
New prob, no work up........................3 points
New prob, work up............................4 points


There's no distinction whether self limited/minor is est. or new.......
So...... what to do?? If you always use "new prob, no work up...." for something that very well could be classified as "self limited/minor" the MDM component is higher than it should.........

I do agree that self limited probs can also be new problems....HOWEVER, new problem or not -  they should be classified as self limited - this better justifies the medical necessity of the issue....

For all the posts about the hx and ex... I KNOW they are also key components of E/M and they have to be met as well depending on the type of E/M....which also help support medical necessity. I also understand that the hx or ex can bring you up or take you down depending on the MDM. *But when you actually taking the MDM in account to determine the level*, if you have moderate (because you used new prob and rx) when it should be minimal (if you have 1 Self limited or minor problem and rx) or Low (if you had 2 Self Limited or minor problem and rx) this is when it makes a difference because the overrall level will be overcoded. 



..........Opinions?? Anyone??


----------



## HCCCoder (Aug 14, 2008)

This replies to ARCPC9491
Well, for est. pt even though the MDM is SF, but you have detailed hx and PE, CPT book clearly states that for level 4,  2 out of 3 must be met (hx, pe, mdm). Therefore, since your Hx and PE are level 4, then your overall LOS is 99214. The truth is truth, there is nothing you can do. I heard CMS is going to change the tools, the MDM part is going to be the first and maybe after that they would say that the 2 out of 3 components must be the MDM. Until we receive the notice, we ARE NOT allowed to change the rules. 
It is different for a new pt, because 3 out of 3 components must be met. In the case where provider documented level 4 Hx, PE and SF MDM, the LOS will drop down to 99201.

Can Lisa provide with a link or a file from CMS that states MDM must be one of the two components met to determine level of service? From my years of experience and from the school too, I didn't study this.


----------



## ARCPC9491 (Aug 14, 2008)

lmartirosyan said:


> This replies to ARCPC9491
> Well, for est. pt even though the MDM is SF, but you have detailed hx and PE, CPT book clearly states that for level 4,  2 out of 3 must be met (hx, pe, mdm). Therefore, since your Hx and PE are level 4, then your overall LOS is 99214. The truth is truth, there is nothing you can do. I heard CMS is going to change the tools, the MDM part is going to be the first and maybe after that they would say that the 2 out of 3 components must be the MDM. Until we receive the notice, we ARE NOT allowed to change the rules.
> It is different for a new pt, because 3 out of 3 components must be met. In the case where provider documented level 4 Hx, PE and SF MDM, the LOS will drop down to 99201.
> 
> Can Lisa provide with a link or a file from CMS that states MDM must be one of the two components met to determine level of service? From my years of experience and from the school too, I didn't study this.






I never said that MDM MUST be one of the two components to determine the level for established pt's- i said WHEN you are USING the MDM component as one of the TWO to determine the level. Example: you have no EXAM - so you must use *MDM and HX *or when you use *MDM and EXAM *with no HX..... 


MDM is ALWAYS in every note - whether it be from a billing/coding/documentation/compliance/ethical/legal/clinical standpoint- MDM will always be present. how many notes have you seen without an A/P? i have never seen one.  

Now, will you ALWAYS have a history and exam? (specific to established patient's) - no you won't ALWAYS have it. (to coding guideline standards) This is why I am saying - that when MDM is USED to determine the OVERALL LEVEL OF E/M - self limited/minor issues are often OVERCODED due to the fact the "new problem, no work up" is given instead of the "self/limited/minor condition" for the MDM component.

*Of course if the HX and EX justify a higher level w/o the use of MDM - then so be it - this is all about when MDM is USED as a determing factor. * but if the HX and EX are the 2 components used - it still has to make sense. i guess i'm just wondering why the HX and EX would stand alone if it wasn't justified w/ MDM? which you resort back to - MDM


----------



## HCCCoder (Aug 14, 2008)

I actually was asking Lisa, because she had the comment about the MDM being 1 of the 2 components met to determine the LOS (post # 12). 
I have never said that there can be notes without an A/P. 
And if you don't have an Exam and you must use MDM and Hx, or when you use MDM and Exam with no Hx, then, still, you have to use the element circled farthest to the left to obtain the correct LOS. And again, MDM does not make an important role here, unless your other component is lower than the MDM.


----------



## Lisa Bledsoe (Aug 14, 2008)

lmartirosyan said:


> This replies to ARCPC9491
> Well, for est. pt even though the MDM is SF, but you have detailed hx and PE, CPT book clearly states that for level 4,  2 out of 3 must be met (hx, pe, mdm). Therefore, since your Hx and PE are level 4, then your overall LOS is 99214. The truth is truth, there is nothing you can do. I heard CMS is going to change the tools, the MDM part is going to be the first and maybe after that they would say that the 2 out of 3 components must be the MDM. Until we receive the notice, we ARE NOT allowed to change the rules.
> It is different for a new pt, because 3 out of 3 components must be met. In the case where provider documented level 4 Hx, PE and SF MDM, the LOS will drop down to 99201.
> 
> Can Lisa provide with a link or a file from CMS that states MDM must be one of the two components met to determine level of service? From my years of experience and from the school too, I didn't study this.



Well, you have me hunting...one place I found supporting information is the Coding Edge https://www.aapc.com/memberarea/resources/coding-edge/february2008/ten-commandments-em-coding.aspx
I'll keep looking for the other locations/supporting documentation I have encountered.  I too questioned this until I recently read several articles supporting this standpoint.  I'll let you know when I find the others.  It might have been in a PART B News article as well, and something is telling me to check out Noridian.  Unfortunately I have a meeting to get to or I'd keep looking.


----------



## ARCPC9491 (Aug 14, 2008)

I found a nice article....  Here's a clip from the AAFP:

Medical necessity
Medical decision making seems to have a special role in determining the level of a patient encounter, even though it's supposed to be weighted evenly with the history and exam. Charles Colodny, MD, a family physician practicing in Libertyville, Ill., who represents the Academy on the AMA CPT Advisory Committee puts it succinctly: "The carriers are well aware that a physician intent on upcoding can increase the level of the history and physical very easily. Medical decision making is something else entirely. This is where they're going to be looking."

Dr. Price agrees wholeheartedly. In a newsletter for participating physicians in his region, he wrote, "It should be the complexity of the medical decision making process and the medical problem which is the most heavily weighted factor determining the E/M service level." Dr. Price made it clear in a subsequent conversation that he views the medical decision making component as a reality check on the other two key elements. While he recognizes that any two of the three can determine the overall level for an established patient visit, he says the physician who consistently "does a great history and a great physical on someone who has a cold" is asking for trouble.

Here's your link .... http://www.aafp.org/online/en/home/...fpm/collections/fpmmedicare/meddecisions.html

*
Bottom line is MDM supports the medical necessity of the rest of the visit and should therefore be the driving factor!

Many practices have their own policies that MDM should be 1 of the 2 key components for established patients to ensure medical necessity is being MET!*

I rest my case.


----------



## dmaec (Aug 15, 2008)

ARCPC9491 - nice link - you should read it again.  I wasn't going to respond to this post again but here I go. 

The only thing your resting is the fact that "you" feel pharynigitis or otitis are self limited or minor issues.
Some of us disagree with that.  I'd never call pharyngitis a minor issue when the provider has decided to run labs and give a prescription. {in fact your article from Dr. Price hits on that very issue} I've seen a sore throat turn to strept and I've seen what strept can do - strept is NEVER minor! He also mentioned things I can't do, like: I can't code "vrs"... so his example of "hypothyroidism vs. anemia" would not help me...can't code it.
You might want to re-read the posts also, it seems to me that those of us who responded to your original post NEVER disagreed with the fact that MDM should support medical necessity.  In fact, quite the opposite, we all agree with that. Again, we seem to be disagreeing on where we'd mark the issue, under self limited or new.

As coders we've all learned (or we will learn) that each facility we work for has their own inside rules.  As for mine - my providers document accordingly. Some times that pharyngitis is a level 2, sometimes a level 3 and sometimes a level 4 - it just depends on patient, issues, and treatment.

Resting the case, great idea!  I agree to disagree on this issue.
_{that's my opinion on the posted matter}again _


----------



## aguelfi (Aug 15, 2008)

*My take*

Donna I like seeing your addendum at the bottom of every post...

Anyway, I was always taught that the medical necessity sets the driving force behind the EXAM.  If the pt is new, the physician still needs to get a full history especially if any rx are going to be given...CYA.  That's makes a hx comp.  I don't think you can do anything about the mdm, it is what it is.  Obviously if the pt is new, it's a new problem to the provider, if an rx is given it's mod, if the pt has phary, oto, sinusitis, you're increasing your # of dx.  You can't change that.  To me the deciding factor is going to be the exam.  However, again, when it's a new pt the doctor may feel it's necessary to perform a more extensive exam because they don't know them and if you have ever worked for a D.O. it's not uncommon for them to look for an underlying condition causing the illness.  Is it medically necessary, sometimes but that's the doctor's call and they have to be able to defend it.  Now, if I saw and eye exam on a broken toe I might question it's validity.  But to make a blanket statement that a phary pt should be a 3 instead of 4 is a little quick.  
And that's my opinion.


----------



## ARCPC9491 (Aug 15, 2008)

This is my final post on this matter - I'm tired of beating a dead horse.

*
Acute otitis media* - SELF LIMITED/MINOR PROBLEM
http://en.wikipedia.org/wiki/Otitis_media

Acute otitis media (AOM) is *most often purely viral *and *self-limited*, as is its usual accompanying viral URI. There is congestion of the ears and perhaps mild discomfort and popping, but the symptoms resolve with the underlying URI. 

This of course *EXCLUDES *bacterial acute otitis media - which normally is accompanied by a fever and is more complex. Which in this case, you get your "New problem and 3 points"

There are other types of OM - but the above 2 are most common.

Pick up a medical dictionary.

So, yes, I agree there are times where OM can be more than just a self limited problem - I never totally disagreed to that. However, half of the time, your classic OM case, is self limited/minor. I guess I didn't clearly state that "more often OM is SELF LIMITED"

To the comment about LABS and other data....of course this will "add" to the MDM....I am speaking specifically when there is NO data - because most of the time, there is none. However, on that note Donna, looking at the table of risk under "minimal" - labs fall under this category anyway. 
So, you have your OM (self limited) labs, (1 point) and Rx (Mod Risk)- OVERALL MDM? MINIMAL/STRAIGHTFORWARD .......... you could even get LOW MDM if the patient had another self limited/minor problem. Just because LABS are ordered - doesn't change the "presenting problem" into something that it is not - it adds to the data component.

*So, with the posts regarding... "Well you can use the HX and EX to get a higher level for established patients..." while the documentation MAY support that higher level... however, the MDM doesn't MATCH the LEVEL OF SERVICE - the HX and EX should support the MDM because the MDM is the driver for the HX and EX!  Everyone is taught "the best/highest 2 out of 3" Not necessarily true! *
_

My ending quote from Ingenix:

If the physicians can sense the level of service that the presenting problems require, they can then be certain to document the history and exam elements required to support the service. This is not to say that a code should be selected, then various amounts of history or exam performed to support it.  Rather, the point is that if the level of decision making describes the real efforts in terms of identifying and managing a problem, and, as is almost always the case, especially with established patients, either the history or exam performed will support that level of decision making – be sure to document these supporting elements. (Ingenix 2003, Coding for Evaluation and Management Services, page 9.)_


The End.


----------



## dmaec (Aug 15, 2008)

abenson said:


> Donna I like seeing your addendum at the bottom of every post...
> 
> Anyway, I was always taught that the medical necessity sets the driving force behind the EXAM.  If the pt is new, the physician still needs to get a full history especially if any rx are going to be given...CYA.  That's makes a hx comp.  I don't think you can do anything about the mdm, it is what it is.  Obviously if the pt is new, it's a new problem to the provider, if an rx is given it's mod, if the pt has phary, oto, sinusitis, you're increasing your # of dx.  You can't change that.  To me the deciding factor is going to be the exam.  However, again, when it's a new pt the doctor may feel it's necessary to perform a more extensive exam because they don't know them and if you have ever worked for a D.O. it's not uncommon for them to look for an underlying condition causing the illness.  Is it medically necessary, sometimes but that's the doctor's call and they have to be able to defend it.  Now, if I saw and eye exam on a broken toe I might question it's validity.  But to make a blanket statement that a phary pt should be a 3 instead of 4 is a little quick.
> And that's my opinion.


lol...Adrianne - yeah, I had to put that in because a couple times when I posted "my opinion", it was misinterpreted as "gospel" or something - like what I said was written in stone somewhere! ... So, to prevent that from happening again - I put my little disclaimer in 
and I agree with your assessment of the posted matter, especially the part about a "the blanket statement".  Very well stated!
_{that's my opinion on the posted matter}_


----------



## dmaec (Aug 15, 2008)

ARCPC9491 - see, now you're adding all sorts of "ifs and buts" and "excludes" and so on and so on.... and that is why when I post, I make it clear that it's my opinion on the _"posted matter".... _ei; your original post.... which is what we all responded to, and it's why we all kept trying to get you to see that just because it's pharyngitis or otitis, doesn't mean it's minor...ALL the documentation and issues MUST be taken into consideration to determine the level of service provided -HPI/EXAM & MDM - it's what we've been saying since first post.  It's all in the documentation.

I'm glad you see it now though. 
_{still, my opinion on the original posted matter- not getting into the ifs, buts & excludes}_


----------



## HCCCoder (Aug 15, 2008)

Dear ARCPC9491,

People are just posting their opinions, based on their experience.
Being the poster of the issue, you should respect our opinions.
You can either agree or disagree, we don't have to know that.


----------



## Lisa Bledsoe (Aug 15, 2008)

lmartirosyan said:


> Dear ARCPC9491,
> 
> People are just posting their opinions, based on their experience.
> Being the poster of the issue, you should respect our opinions.
> You can either agree or disagree, we don't have to know that.



True!  These posts are just that - opinions and sharing our experience and how we were taught.  Sometimes we even learn a thing or two!  That's the beauty of it! The forum is not meant for arguments - simply discussion and sharing!  I have learned A LOT from the forums and am extremely thankful that the Academy has provided this opportunity for us!


----------



## dmaec (Aug 15, 2008)

I agree - I've learned a LOT on these forums. from others points of view and experiences!


----------



## HCCCoder (Aug 15, 2008)

Me too, I love this forum. 
Thaks a million, AAPC !!!!!!


----------



## aguelfi (Aug 18, 2008)

I can't tell you how many times I have turned to you guys/girls for your opinions on how to code something or for a different perspective on sometime.  Sometimes we need to look at things from outside the box, and I want to thank you all for your help and opinions.

Oh and I am in the direct path of TS Fay...please say a prayer.  We were completely destroyed by Charley 5 yrs ago.


----------



## RebeccaWoodward* (Aug 18, 2008)

I've been watching this one from the side lines and have been impressed with the passion in everyone's comments/opinions.  I can certainly understand when someone feels that their "case" isn't being understood or possibly rejected,however; it is important to remember that we're a team.  Once you begin to "burn bridges", it's very hard to repair them.  There is always a place for constructive criticism but it must, also, be done with tact.  I recently misunderstood someones comment on a post and another member of this forumn kindly pointed that out to me.  

"Teamwork is the ability to work toward a common vision"


----------



## amolson1325 (Aug 18, 2008)

Adrianne~
Are you in Pt Charlotte? I'm up here in Sarasota and we are preparing also. They are saying it won't even be close to Charlie....but you never know huh. We actually thought we were going to get Charlie but it made that turn! As they say "Hunker Down" 




abenson said:


> I can't tell you how many times I have turned to you guys/girls for your opinions on how to code something or for a different perspective on sometime.  Sometimes we need to look at things from outside the box, and I want to thank you all for your help and opinions.
> 
> Oh and I am in the direct path of TS Fay...please say a prayer.  We were completely destroyed by Charley 5 yrs ago.


----------



## Lisa Bledsoe (Aug 18, 2008)

rebeccawoodward said:


> I've been watching this one from the side lines and have been impressed with the passion in everyone's comments/opinions.  I can certainly understand when someone feels that their "case" isn't being understood or possibly rejected,however; it is important to remember that we're a team.  Once you begin to "burn bridges", it's very hard to repair them.  There is always a place for constructive criticism but it must, also, be done with tact.  I recently misunderstood someones comment on a post and another member of this forumn kindly pointed that out to me.
> 
> "Teamwork is the ability to work toward a common vision"



Very well put Rebecca!


----------

