Practice Management Alert

Question: My practice has hired a new provider, and the new provider’s notes, which they compile using the practice-wide electronic health record (EHR) system, are difficult to decipher. I can never find a diagnosis code, even though I’m sure the patients aren’t just visiting to chat. One of my responsibilities as a coder is to select the evaluation and management (E/M) medical decision making (MDM) code, and I don’t think I can do so without a diagnosis. Is it even possible to evaluate MDM without a diagnosis?

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Answer: Whenever a practice onboards a new provider, teaching the ropes should involve going over everything the provider needs to know to do their job. Of course, the provider should come armed with the necessary clinical knowledge, but they may not have used the EHR system your practice uses nor worked with in-house coders or auditors who can provide them with the education they need to make everyone’s jobs easier.

Talk to the provider and find out some more information.

Are they making diagnoses? Is your EHR system configured in such a way that the diagnosis selection does not show up on the summary of the notes for an encounter? Is there some additional step they need to take between selecting a diagnosis, perhaps from a drop-down menu, and the chosen code or phrase showing up in the final note? The provider probably isn’t doing anything to deliberately make your job more difficult — or withhold crucial information from any patient’s health records.

Although you didn’t include an example of a note, it’s fair to say that evaluating medical decision making without knowing what decisions were made would prove difficult. See whether you can figure out what’s happening on the front-end of the documentation, and whether any easy fixes, in the form of education, can help.