Practice Management Alert
Reader Questions:
Use This Simple Note to Boost Evidence of MDM
Published on Mon Jan 17, 2022
Question: The providers I work with frequently refill patients’ medications. I’ll see “refill mediations per EMR” [electronic medical record] on the chart, but I feel like I need more information to be able to justify, through documentation, that the clinician is providing medical management for the patient. What should I do? Michigan Subscriber Answer: The easiest thing you can do may be to ask the clinicians to specify each prescription drug being refilled. This would provide more documentation to support the moderate complexity medical decision making (MDM), as well as help generally bolster the accuracy and thoroughness of the respective patient’s medical records — electronic or otherwise.
Other Articles in this issue of
Practice Management Alert
- Telehealth:
Take Note Now of These OIG Work Plans Surrounding Telehealth
Add ‘telefraud’ to your compliance lingo dictionary. Telehealth expansion grew at such an immense rate [...] - Administration:
Why a Virtual Scribe May Work for Your Practice
Weigh the pros of thorough documentation against potential exposure or patient embarrassment. The idea of [...] - Audits:
Shore Up Your E/M Coding With These Best Practices
Bonus: Your reimbursement may get a boost, too. Evaluation and management (E/M) service claims are [...] - Reader Questions:
Don’t Worry About Vaccine Brand Name
Question: I am looking for a CPT® code for the Fluarix flu shot but can only find [...] - Reader Questions:
Prepopulating Encounter Notes Is Always a No-No
Question: One of the certified medical assistants (CMAs) at my practice sometimes helps out as a [...] - Reader Questions:
Use This Simple Note to Boost Evidence of MDM
Question: The providers I work with frequently refill patients’ medications. I’ll see “refill mediations per EMR” [...]
View All
