Wiki Couple E/M question gray aeas to me. Advice please?!

[AmandaW]

My first question is in regard to the 95 and 97 guidelines and when Medicare -RAC does an audit.
Will they use the guidelines that suits THEM or will they always use the guidelines that benefits the physicians?

Also, if it's an established patient and you need 2 out of 3...history and exam are perfect-comprehensive but MDM lacks complexity, can you still do a moderate using the history and exam, and not MDM?

And if I'm in a urology specialty but the patient has diabetes, CHF, COPD, basically things that the dr doesn't necessarily treat, but might need to make medical decisions around that, can I bill those diagnoses? Or is it a matter of IF they put it in the assessment and plan? What if they put it there and list it. Can I count those as a point for established problem?
Do they actively have to be treating it on that encounter date? Where I'm struggeling is that they are not 'treating' the diabetes, etc. but it could be a factor in decision making.

 

[mflewis]

Reply to thread

The RAC audits are supposed to use either the 95 or 97 Guidelines which best suit the practice not the auditors. As you know many appeals are done to the audits with their with majority of them favoring the provider.
In the Federal Register this fall, CMS was indicated that it is the MDM that should determine the amount of work done, that is the history and examination. With the use of the EMR. the HX and EX have become relatively easy to clone, but should not be used as components if there is no medical necessity to do them.
M, Lewis, CMM, CPC, CP-I, CPMA, CCS-P