Wiki Help! Auditing tool "loop holes"

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KGerlings

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I am currently working with an IP pediatrics group. One of the physicians has some questions he would like to argue, and while I vehemently disagree, I am having a difficult time locating sound evidence in favor of either of out arguments. Any help would be wonderful!

Issue #1 We were reviewing a H&P with 4 problems, no additional work-up. 1- Seizure 2- Vomiting 3-Hematochezia 4- Diaper rash. I calculated 4 new problems, no additional work-up planned. This category has a max allowed of one problem x 3 points for a total of 3 points. The physician I am working with said he counted only one of the problems towards "new problem with no additional work-up" and he counted the other three problems, (with a max of two) for self-limited or minor. This gives him a total of 5 points. He agrees these are not self-limited or minor problems, but cannot fathom that one would receive fewer points (3) for taking care of several problems. He feels once the new problem maximum is fulfilled, all remaining problems should be considered under the self-limited or minor category. Anything more concrete I can show him to sway his opinion beyond pointing out that the category is designated only for self-limited or minor problems and these are not?

Issue #2 The patient is seen on day 1 with abdominal pain. On day 2 an x-ray reveals "significant fecal burden" with plan for an enema. The other physicians and myself agree that the abdominal pain on D1 is a sign/symptom of the fecal burden and therefore is an established problem. However, this one physician begs to argue that the fecal burden is a "new problem" because it was not present and documented on D1. Again, while I disagree with him, I am looking for something more concrete to prove this to him. Any ideas?

Thanks a ton!
 
I would review the above as follows:

#1 - if the problems are new to the provider, then it is impossible to impose them as self-limited. However, if it is an established patient and the problems are previously documented and the visit indicates there is not an issue with the problems then I would consider them self limited.

#2 - The problem is the same problem except now the MD has definitive information so it is not a new problem. It could be considered an established problem that is worsening. The MD is trying to split hairs here and needs to realize the patient is in a course or treatment and the signs and symptoms were the first visit and with further testing, a more definitive problem was discovered. It is the same course of treatment for the same problem
 
Self-limited or minor

I disagree ... a NEW problem can definitely be self-limited or minor.

Diaper Rash would probably fall in this category (depending on how serious it was ... if the only treatment plan is Desitin and changing diapers more frequently, then that's pretty minor)

I would NOT, however, automatically count everything after the first New problem w/o workup as "minor or self-limited" ... it would totally depend upon the presentation / symptoms / treatment plans.

BTW ... I'm stunned that there would be no additional workup for a chief complaint of SEIZURE ...

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
FTessaBartels said:
I disagree ... a NEW problem can definitely be self-limited or minor.

Diaper Rash would probably fall in this category (depending on how serious it was ... if the only treatment plan is Desitin and changing diapers more frequently, then that's pretty minor)

I would NOT, however, automatically count everything after the first New problem w/o workup as "minor or self-limited" ... it would totally depend upon the presentation / symptoms / treatment plans.

BTW ... I'm stunned that there would be no additional workup for a chief complaint of SEIZURE ...

Hope that helps.

F Tessa Bartels, CPC, CEMC
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I really wish we had "Like" buttons on here.....
 
Just throwing this out there...

Was the xray ordered on day 1 for the seizure dx? If not when was it ordered and what was it ordered for?

I also do not see how a primary Dx of Seizures could be catagorized as a self-limited or minor problem.

There's just not enough information for me to make a concrete judgement call on this one. There are a lot of factors that come into play in regards to MDM. Medical Necessity IS one of the risk factors however, but not necessarily the driving force. It all depends on the cognitive process and documentation of problem management of the provider to defend the level chosen.
 
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