Wiki E/M and Presenting Problem(s)?

[jlworkmon]

My company has recently made a drastic change and is failing me on my audits because I don't put at least 2 presenting problems on every encounter. On my audit logs it specifically sites being able to increase the E/M as the reason to add a second PP. This does not feel legal to me. Am I overreacting?

 

[thomas7331]

My company has recently made a drastic change and is failing me on my audits because I don't put at least 2 presenting problems on every encounter. On my audit logs it specifically sites being able to increase the E/M as the reason to add a second PP. This does not feel legal to me. Am I overreacting?

Are you speaking as a provider or as a coder? There is no coding requirement that there must be 2 presenting problems. Coders are required to code according to what is documented, whatever that may be. If as a provider, I would think you would be required to document accurate what the presenting problems were. You can't put down two presenting problems if the patient only came in with one. Or perhaps I'm not completely understanding what you're asking?

 

[wbrodsky]

Are you speaking as a provider or as a coder? There is no coding requirement that there must be 2 presenting problems. Coders are required to code according to what is documented, whatever that may be. If as a provider, I would think you would be required to document accurate what the presenting problems were. You can't put down two presenting problems if the patient only came in with one. Or perhaps I'm not completely understanding what you're asking?

This is absolutely true, whether a coder or physician. If the pt only has 1 presenting problem, you cannot simply just add one to get more points in the E/M scoring. Also, keep in mind, just because you have 2 Dx codes, doesn't mean your level will still raise. You have to be doing work with the problems at hand, as well as get a Comprehensive Hx and Exam. Established pts won't matter so much in the MDM as only 2 of the 3 areas (Hx, Exam, & MDM) are counted (the lowest is dropped), so even if the pt has only 1 presenting problem, you could still code a level 5 if you meet the Hx and Exam sections at Comprehensive which is easy to do. For a New pt, this will be more difficult as you can't make someone sicker than they are. If a pt only comes in for a cough, and that's the only issue, you cannot make up others. Now, you can find out if there are other symptoms that you could possibly add, but if it isn't notated, it didn't happen.