Wiki Physical Medicine and Rehab Auditing

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dhyler

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Hello, does anyone out there have experience with coding for PM&R? hospital and/or office charts? I am having some trouble making sure the physician meets the level billed when I do not understand exactly the process of what is what? Please help!!:(
 
Mdm

I should add that it is the MDM that is stumping me, as the doctor is putting every condition the patient has and what is going on with each system and I do not know what I am to count for established problems. does this make sense? I will appreciate any input...
 
you would only count the conditions that he is actively treating that patient for or for conditions that affect his treatment. Like if he is treating back pain and the patient also has breast cancer, he would not be listing the cancer diagnosis in his assessment. Each condition has its own set of "points" whether it is stable or improved or worsening. He needs to document as such. Do you have an audit form that you are using? Email me at teresak30@yahoo,com if you do not and I can email you the one that I use at my job.
 
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