kimberagame
Contributor
My clinic has been pushing me to query a provider when an office visit note would qualify for a higher E/M based on the MDM, but is missing the required documentation in the history and/or physical portion of the note. Our administrator feels that the providers aren't getting paid for the work they're doing and we need to help them get what they're entitled to. He believes they're legitimately leaving out details that would allow them to get that higher visit level, and we should be approaching them to enquire whether that's the case when we come across these visits. So, for instance, we should task and ask if they really only asked one ROS question, or were there maybe more that they just didn't add. Or can they provide any more details about the patient's pain that would get them to 4 HPI points? I've refused so far, as my understanding was this was not allowed. We can educate providers on what they need to have in their notes, but we can not go back after the fact and ask them if there's more they could add. It looks too much like we're having the provider add things that didn't really happen to the note to increase their level. But they're pushing again. I've tried to find documentation to support my argument, but had no luck. Does anyone know where I could look? Or am I wrong about this to start with? Our administrator is a former coder, and he feels quite strongly that this is fine. Thanks for any feedback!