Primary Care Coding Alert

Teach your physicians to write iron-clad MDM notes.You can't get inside your physician's head to know whether his MDM (medical decision-making) warrants the E/M service code that he reported -- but beware that Medicare auditors are zooming in on this area when examining E/M claims.Auditors aren't scrutinizing the exam or history as much as they weigh the factors related to medical decision-making. But you can be your physician's front line of defense and make sure his notes withstand scrutiny if you follow these tips.Tip 1: Identify a Mismatch With This StrategyIn your next staff education meeting, remind your FPs that medical necessity should be the overarching factor they use to select the E/M service level (such as 99201-99215, Office or other outpatient visit for the evaluation and management of a new or established patient ...). Just because a physician completes a comprehensive history and examination doesn't mean he always should report [...]