Medicare Compliance & Reimbursement
This MAC Spells Out 'High Risk' MDM Component
If you’re trying to achieve a higher medical decision-making (MDM) level because your patient gets insulin drips, your documentation must include specific criteria or your “high risk” MDM could be out the window. That’s the word from Palmetto GBA’s recent “E/M Weekly Tip,” which the MAC posted on March 24.
“An intravenous insulin drip is considered ‘high risk,’” Palmetto says. “To consider therapy with one of these drugs as a high risk management option, we would expect to see documentation in the medical record of drug levels obtained at appropriate intervals.”
In short: If your practitioner is not periodically recording drug levels, your documentation won’t be strong enough to count the insulin drip as a high-risk option. Practices that see a lot of patients for this purpose should check the medical records thoroughly for this information, and if you don’t see it, educate the practitioners about its importance.
Resource: To read Palmetto’s weekly tip, visit www.palmettogba.com
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