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Kenneth Patric MD
Reply with quote  #1 

Our coding consultant tends to down code our visits even when they meet the at least 2 of the 3 elements because she states CMS will look at the at the "medical necessity" of of our HPI, ROS, and Physical and reduce the items we have checked based on the diagnosis. I did not see this process in your coding determination. Can you speak to that?

pjensen

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Reply with quote  #2 
If you take the paid courses, you will see that we address this topic very clearly.  The over-arching criterion for determining the level of care is the medical necessity of the encounter.  You have to calibrate the intensity of the history and exam to match this medical necessity.  For example, it is only cool to perform and document a comprehensive physical exam if it is medically necessary to do so (which means you can't do a comprehensive exam for an otherwise healthy 30 year old with an earache).  If elements of history or exam are not supported by the medical necessity of the encounter, these items will probably be "disallowed" on an audit, which would decrease the level of care.

PJ
dvoegele

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Reply with quote  #3 
How do you know what to down code to if you have
Doctors that always do comprehensive hpi,ros, and exams
Regardless of the cc.
pjensen

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Reply with quote  #4 

I would look to the MDM required for the encounter.  Medical necessity is always the over-arching criterion for the level of care.  I always use the MDM as one of the qualifying key components (even for those 2 out of three encounters).  The level of history and exam must be supported by the medical necessity.  If, not then those elements should not be counted.  You can't do a comprehensive history and exam on every single patient simply because you have the time and incliniation (or a tricked out EMR).  You can only perform and document this level of history and exam if it is MEDICALLY NECESSARY to do so.

dvoegele

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Reply with quote  #5 
I have signed up for your paid courses. I got all of them
Which one particular address the medical necessity and ndm correlation
I code for the er
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