Medicare Compliance & Reimbursement

Physician practices' MDM levels will be in auditor's crosshairs.

When Medicare sends auditors to look at evaluation and management claims, they're going to zero in on doctors' medical decision making, experts say.

Auditors aren't scrutinizing the exam or history as much - "they definitely weight [the audit] toward medical decision-making," says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, ID. The problem is that even if you're a physician keeps spotless records of history and exam, the practice could wind up downcoding or facing audits if the medical decision making doesn't tell a good story, say billing experts.
 
The easy part: Documenting exam and history is often easier for physicians because these elements represent concrete actions. "The more E/M services I audit, and the more different types of physicians I talk to about this, the more I realize that it's not too difficult to teach physicians how to list all the bullets in the exam," says Marcella Bucknam, HIM coordinator with Clarkson College in Omaha, NE. But getting the physician to explain the thoughts behind a set of decisions is much harder.

To dramatize the process that goes into the final decisions providers make, practice managers should encourage doctors to express the difficulty of decision-making. Providers need to learn to give a step-by-step account of their thoughts and considerations when deciding on treatment.

And physicians should spell out the risk to the patient if they don't treat a problem, says Webb. "If they don't treat it, what are your risk factors" Also, what are the risks of treating the problem incorrectly? Providers should document all of these things," she explains.