# help with auditing question



## CINDYMALONE (Mar 21, 2013)

it has been a discussion lately in my office about what we were taught in how to audit a chart correctly. we were taught that  you need two of three elements of the HISTORY, EXAM AND DECISION MAKING. now we are being told that the decision making has to be one of the two choices. can someone please clarify this dilema for us. 

thanks


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## Peter Davidyock (Mar 22, 2013)

I teach my physicians to begin with the MDM. So by default for me anyway it's always part of it.


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## dseyfried (Mar 23, 2013)

MDM is not a required component.  It's two of three for established,  3 of 3 for new.


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## kparkhurst (Mar 25, 2013)

Although MDM is not a required component, it does help to support medical necessity of the visit. I also teach my physicians to start with the MDM as it should be the driving force in their documentation. I would greatly recommend it!


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## mhstrauss (Mar 25, 2013)

kparkhurst said:


> Although MDM is not a required component, it does help to support medical necessity of the visit. I also teach my physicians to start with the MDM as it should be the driving force in their documentation. I would greatly recommend it!



Check with your MAC for guidance.  Some do require MDM to be 1 of the 2 deciding factors; mine (Novitas) does not.


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## daguilar@swgiassoc.com (Mar 25, 2013)

*Chart Audit*

Can anyone give me tools/materials/guides that can be used in a chart audit for a GI
practice ?   Appreciate the help.


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## MikeEnos (Mar 25, 2013)

MDM does NOT have to be 1 of the 2 key components for an established patient visit (which requires 2 of 3 components to meet or exceed the requirements to bill for a level of service.)

I'm not sure where this "MDM must be 1 of the 2" rumor comes from, I've heard it a few times before.  I've never heard of anybody requiring the MDM to be one of the 2.  Of course, we all know that medical necessity must support the level of history an exam performed.  M*ake no mistake -- Medical Decision Making IS NOT medical necessity! * MDM is a matrix of check-boxes and grids that a very had-working panel came up with to attempt to quantify the cognitive labor that goes through a physician's mind when they are treating patients. It is fairly reliable, but it is not the be-all-end-all final say on what level of service was provided.  Many coders and auditors are not clinicians, so it's not our place to arbitrarily decide which elements of the history or exam were medically necessary.  

Let me give you an example to illustrate the point:
-Let's say a patient sees their oncologist for follow-up of their cancer.  They have a 10-year history of cancer, and they have had reoccurence once before.  Right now they are cancer-free but they have a check-up periodically to make sure there is no reoccurence.  The oncologist documents a detailed interval history, and performs a detailed exam (like you would hope if you were the pt!)  The MDM may calculate to low.  

Diagnosis Points - Stable, established problem - 1 point
Data points - Order/review radiology tests - 1 point
Risk - One stable chronic problem - Low risk
__________________________________
Straight-Forward Medical Decision Making  Complexity

So in this case, we have a follow-up of cancer, the oncologist performed a detailed exam and documented a detailed history -- should we hold them to a level 2 service just because the patient ended up showing no signs of reoccurence of cancer??  I would say no- it is certainly medically necessary to perform a detailed history and exam, and a level 4 service is justified here.


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