kterry0474
Contributor
My office has recently had an audit by an outside vendor. This was set up by our higher ups. Our providers had to get 9 out of 10. correct in order to pass. What I found was they do nto like us billing level fours, almost all we downcoded. I audited the charts myself adn recieved confirmation from the other CPC in the office. I contacted our compliance officier and she stated ever though we had 2 out of 3 the decision making was low (in their minds) and they downcoaded then to level 3. I have attached a chart note as an example.
She stated that the main decision is the MDM because that is what AMA, CMS and OIG are stating and should be the deciding factor. Please note that we ONLY count what is pertinant to the visit. I would appreciate any information that you may give me!.
Established Patient Visit health depart
PCP: HEALTH DEPT
CHIEF COMPLAINTS: Followup of Atypical Squamous Cell Changes Of Undetermined Significance Favor Benign.
HISTORY OF PRESENT ILLNESS:
On 11/04/2013, a 34 year old female, LMP 10/30/13 , G 2 P 2 0 0 2 using as her birth control tubl ligation.
- presents for pap. was seen5 months ago after abn pap at health dept. pt is HIV pos and has longstanding hx of abn paps, had LEEP several years ago. COlpo was done with nml findings. she is currently undergoing surveilence with pap q 6 months until 3 consecutive nml paps
HEALTH MAINTENANCE HISTORY (dates may be approximated):
REVIEW OF SYSTEMS:
General: no fever, chills, or body aches
G/U: no dysuria, urgency, frequency or incontinence. No abnormal menstrual bleeding or symptoms
GYNECOLOGICAL HISTORY:
Current Contraception - tubl ligation
Last Pap Smear Date - 03/2013
Last Pap Smear Report - abnormal by history
Abnormal Pap Smear - Hpv
Last Mammogram Date - None
Bone Density Scan Date - None
Colonoscopy Date - None
Breast Lump - No
Fibroids of Uterus - No
No. of Sex Partners - 5
Ovarian Cysts - No
Sexual Abuse - No
Sexuality Concerns - Burning
STD's - HIV
Unprotected Sex - No
Urinary Tract Infections-No
Vaginal Infections - BV in past, during pregnancy only in past and yeast in past
Menopausal Symptoms - night sweats
Urinary Incontinence - No
Last Cholesterol Check Date - None
MEDICAL/SURGICAL HISTORY:
Infections - Chicken pox and HIV
Illnesses - Bronchitis
Accidents/Hospitalizations - car accident
Surgeries - Tubal ligation, conbiotgy and Cesarean section
Emotional Problems - none
PRESENT MEDICATIONS:
1. 3 eye drops
2. asentress
3. norvair
4. prevista
5. vireid
ALLERGIES:
NKDA
MENSTRUAL HISTORY:
LMP 10/30/13
Amount/Duration Normal
Regularity Regular
Menstrual Cycle Length 5-7 days
PHYSICAL EXAMINATION:
VITAL SIGNS:
BP: 120/84 mmHg -
Weight: 259.00 Lbs.
Height: 63 In.
BMI: 45.87
LMP: 10/30/13
GENERAL EXAM:
CONST.: well nourished, well developed, no acute distress
NEURO: alert, oriented x3, no focal signs, mood and affect appropriate
PELVIC EXAM:
VULVA: no external lesions, normal hair distribution
URETHRAL MEATUS: no lesions, eversion, or stenosis
URETHRA: non tender, no masses, no discharge, well supported
BLADDER: no tenderness or masses, well supported
VAGINA: normal rugae, adequate support, no discharge, lesions, or erythema
CERVIX: no lesions, no discharge, non friable
UTERUS: normal size, mobile, nontender, smooth in contour, normal consistency, adequate support
ADNEXA: no adnexal masses, nodulularity or localized tenderness
ANUS & PERINEUM: intact w/o lesions, rashes, fissures, fistulas, or symptomatic hemorrhoids
RECTAL: normal sphincter tone, no palpable masses
DIAGNOSTIC TESTS:
Thin Prep Pap /HPV Rflx 16/18
DIAGNOSES:
1. Atypical Squamous Cell Changes Of Undetermined Significance Favor Benign Unchanged
PLAN NOTES:
pap collected, if nml, will repap in 6 months, if abn, will plan to repeat colpo. Pt understands
She stated that the main decision is the MDM because that is what AMA, CMS and OIG are stating and should be the deciding factor. Please note that we ONLY count what is pertinant to the visit. I would appreciate any information that you may give me!.
Established Patient Visit health depart
PCP: HEALTH DEPT
CHIEF COMPLAINTS: Followup of Atypical Squamous Cell Changes Of Undetermined Significance Favor Benign.
HISTORY OF PRESENT ILLNESS:
On 11/04/2013, a 34 year old female, LMP 10/30/13 , G 2 P 2 0 0 2 using as her birth control tubl ligation.
- presents for pap. was seen5 months ago after abn pap at health dept. pt is HIV pos and has longstanding hx of abn paps, had LEEP several years ago. COlpo was done with nml findings. she is currently undergoing surveilence with pap q 6 months until 3 consecutive nml paps
HEALTH MAINTENANCE HISTORY (dates may be approximated):
REVIEW OF SYSTEMS:
General: no fever, chills, or body aches
G/U: no dysuria, urgency, frequency or incontinence. No abnormal menstrual bleeding or symptoms
GYNECOLOGICAL HISTORY:
Current Contraception - tubl ligation
Last Pap Smear Date - 03/2013
Last Pap Smear Report - abnormal by history
Abnormal Pap Smear - Hpv
Last Mammogram Date - None
Bone Density Scan Date - None
Colonoscopy Date - None
Breast Lump - No
Fibroids of Uterus - No
No. of Sex Partners - 5
Ovarian Cysts - No
Sexual Abuse - No
Sexuality Concerns - Burning
STD's - HIV
Unprotected Sex - No
Urinary Tract Infections-No
Vaginal Infections - BV in past, during pregnancy only in past and yeast in past
Menopausal Symptoms - night sweats
Urinary Incontinence - No
Last Cholesterol Check Date - None
MEDICAL/SURGICAL HISTORY:
Infections - Chicken pox and HIV
Illnesses - Bronchitis
Accidents/Hospitalizations - car accident
Surgeries - Tubal ligation, conbiotgy and Cesarean section
Emotional Problems - none
PRESENT MEDICATIONS:
1. 3 eye drops
2. asentress
3. norvair
4. prevista
5. vireid
ALLERGIES:
NKDA
MENSTRUAL HISTORY:
LMP 10/30/13
Amount/Duration Normal
Regularity Regular
Menstrual Cycle Length 5-7 days
PHYSICAL EXAMINATION:
VITAL SIGNS:
BP: 120/84 mmHg -
Weight: 259.00 Lbs.
Height: 63 In.
BMI: 45.87
LMP: 10/30/13
GENERAL EXAM:
CONST.: well nourished, well developed, no acute distress
NEURO: alert, oriented x3, no focal signs, mood and affect appropriate
PELVIC EXAM:
VULVA: no external lesions, normal hair distribution
URETHRAL MEATUS: no lesions, eversion, or stenosis
URETHRA: non tender, no masses, no discharge, well supported
BLADDER: no tenderness or masses, well supported
VAGINA: normal rugae, adequate support, no discharge, lesions, or erythema
CERVIX: no lesions, no discharge, non friable
UTERUS: normal size, mobile, nontender, smooth in contour, normal consistency, adequate support
ADNEXA: no adnexal masses, nodulularity or localized tenderness
ANUS & PERINEUM: intact w/o lesions, rashes, fissures, fistulas, or symptomatic hemorrhoids
RECTAL: normal sphincter tone, no palpable masses
DIAGNOSTIC TESTS:
Thin Prep Pap /HPV Rflx 16/18
DIAGNOSES:
1. Atypical Squamous Cell Changes Of Undetermined Significance Favor Benign Unchanged
PLAN NOTES:
pap collected, if nml, will repap in 6 months, if abn, will plan to repeat colpo. Pt understands