I agree with Debra. Most physicians do not know coding rules. The 18 physicians in our practices do a preliminary code--As a nurse, certified auditor and coder, I'am frequently changing their codes and attempting to educate them. (Counting ROS elments (etc) is not a MD priority.) If a coder does not have the medical perpspective to judge severity/risk they need to communicate with the physican on that case. Since I'm not a physician, unless the MDM is really clear cut --I will let them have the benefit of the doubt with the MDM. However, you have to stand up to them--if the required elements are not documented--it doesn't fit the code period. After 30 years of nursing, I'm not going down for assisting fraudulent behavior by agreeing that every patient Dr. X touches is a level 5, just because he says so!
Maryann Fisher, RN, MS, CPC, CPC-H, CEMC, CPMA, CPCO