I'm gonna go out on a limb here...
I'm betting maudys already knew all of this...Sounds like there was a disagreement to settle...
If the guideline says that 3 out of 3 components must meet or exceed the code descriptor, then you have to have all 3 for each level. Here's some unsolicited insight that could help, if my assumption is correct...
:
(I'm dealing with this issue in my audits at the moment...) I've found 3 documentation habits that seem to consistently lead to these dilemmas...
1. Doctors are
performing a more extensive history and exam than is considered 'medically necessary' for the nature of the presenting problem (eg, documenting a comprehensive Hx and exam for a patient with a simple sprain)... [See:
http://oig.hhs.gov/fraud/PhysicianEducation/roadmap_speaker_notes.pdf]
[
http://oig.hhs.gov/fraud/PhysicianEducation/]
I think it's kind of crappy, since the doctors are really just providing high quality of care, and probably catch more problems than those that only do the bare minimum. But the payers don't see it that way. If you took your car to a mechanic, and asked to have the oil changed; but the mechanic
also gave it a complete tune up, replacing all of your fluids, filters, spark plugs, windshield wipers, battery -
and rotated and balanced your tires; You might think that he's an excellent mechanic if you only had to pay a small portion of the bill, but you'd probably feel scammed if you were charged for all of the extra services that he provided, without really needing to.
2. Doctors are
documenting a more extensive history and exam than is considered 'medically necessary' for the nature of the presenting problem. This is not to be confused with #1. These doctors misuse EHR Macros and templates to complete an encounter note that attempts to technically meet the CMS requirements. You can tell when you see these, because the information provided doesn't make sense, seems irrelevant, and/or is inconsistent, with contradicting notations. These doctors could benefit from some education on documentation requirements, particularly with ICD-10 just around the corner, which requires even more specfic documentation, due to the level of detail required in the codes. Understanding the purpose of each of the documentation and coding requirements, makes it easier to comply with them, and helps to eliminate records filled with information that only helps to occupy space.
3. Doctors are unable to get enough 'points' in the MDM category, due to missed opportunities in documentation. (For example, are they documenting that they gave the patient education on what do do when they get home, to care for themselves? How about telling them to "take it easy", "get lots of fluids", or "use an ice pack"? - those add points to the number of management options.) They should be mindful when documenting the assessment and plan, that it's meant to be the 'overall summary' of how bad the patient's condition is. If a condition is complicated by another chronic illness, its prognosis, severe symptoms, or other reasons that led to the doctor performing a Comp H&P, then he's got to convey the difficulty/complexity through his notes. The written English language is said to be the most deceptive, because words can have different connotations, when presented in different ways - particularly without much context to help with making inferences. Doctors' notes should really paint a picture of how serious or complicated they think that each encounter is, including making notes of their thought processes that led to the decisions they made. It doesn't have to be a novel; just detailed enough so that someone without mind-reading abilities can tell what they were thinking.
Anyways, maybe that can help you out...have a good weekend!
