Part B Insider (Multispecialty) Coding Alert

Make providers describe the decision-making, or your audit could be a tragedy

When Medicare sends auditors to look at your evaluation and management claims, they're going to zero in on your 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: Even if your physician keeps spotless records of history and exam, you could find yourself downcoding or facing audits if the medical decision-making doesn't tell a good story, say billing experts. Think of the medical decision-making as a window to the doctor's thoughts as he or she determined a treatment, not just as a record of what the physician decided.

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.
 
Emphasize Details in Documentation

Solution: To dramatize the process that goes into the final decisions your providers make, you should encourage them to express the difficulty of decision-making. "I encourage physicians to say things like 'deciding on the exact treatment here was very difficult,'" says Bucknam, "instead of the cut and dried statements they tend to make." 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.

Editor's note: For more specific guidance on beefing up your MDM documentation go to story: "Look For Signs of MDM Thought Process", this issue.