Wiki Mdm help!!!

[alb0421]

I Audit Hospitalist charges and need some clarification on "Parenteral controlled substance". On an H&P- The patient is there for abdominal pain, nausea, vomiting. HPI, ROS, PFSH, Exam- all Comprehensive. When you get to the MDM, the patient is diagnosed with diverticulitis (new problem) the provider puts the patient on IV antibiotics, IV dilaudid for pain, and orders more labs and a repeat colonoscopy, etc. (with additional workup)

I would give 4 points for the DX and mgmt options
I gave him 2 points for data points- he reviewed and ordered labs, and reviewed a CT

Would you give this patient a high in the risk area for IV dilaudid since it falls under "parenteral controlled substance" on the table of risk and bill a 99223?

 

[thomas7331]

It's a little hard to judge definitively without seeing the documentation and the physician's assessment of the patient's condition and prognosis, but based just on what you've said you're auditing looks correct and I would agree that this qualifies as high risk and meets the criteria for a 99223.

 

[thomas7331]

I agree with your line of thinking on this. I don't think you'll find anything in writing from CMS that goes to that level of detail on E&M auditing, though some of the individual MACs do have good Q&A on their web sites that gives you a clue into how they see these things. Also, the key here is not the level of risk of the presenting problem, but the medical necessity of the total level of service to treat that problem that CMS is concerned about, and that's largely a clinical determination. From a purely coding standpoint, if you're following your audit guidelines and can point to elements in the documentation to support an appeal to explain why you chose the code that you did, then you're doing your job correctly.