Medicare Compliance & Reimbursement

Physicians can improve documentation by following these tips.

A physician's operative notes may have a history and physical exam as spotless as mother's china, but if the medical decision-making (MDM) is weak, auditors can come and shatter the claims to pieces.

Luckily, experts have a few suggestions to help physicians repair the medical decision-making section of their claims. Use these tips to make MDM documentation a breeze:

1. List complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking or adverse reactions the patient had to previous medications, says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, ID. 2. Include detail in notes about tests and medications administered, advises Jean Keller, an auditor with Applied Medical Services in Durham, NC. Coders can find important MDM details in these sections.

3. On level 4 and 5 visits, dictate records instead of using a checklist or template, says Keller. Some templates don't give enough room to explain why the physician made some decisions, and often physicians won't even use the spaces provided.

4. Don't assign a level four or five just because the physician documented lots of activities. Look for a story that justifies the medical necessity of a higher level. The "pendulum is swinging back" toward medical necessity as the main criteria for judging the need for E/M services, Webb says.

5. Physicians should make it clear when they take an intermediate step that they don't believe will solve the patient's problem. For example, they may try physical therapy before resorting to surgery - or antibiotics before a more aggressive treatment. When a physician explains that he's trying the more conservative treatment, but that the patient may require a more aggressive approach, it can boost the level of MDM.