Medical Coding Auditor Training

Tammy: Q: Is there any way I can get some
insight on an audit situation? Established patient came in for an earache. History documented
was comprehensive. Exam was EPF (expanded problem focused). In the MDM (medical decision
making), this was new problem to provider, with no additional work up planned, which
is 3 points. The complexity and data reviewed is minimal. No lab, x-rays ordered. The risk
was moderate. There was a prescription wrote for the ear. This is sort of a gray area.
The presenting problem is straightforward, but the documentation supports moderate medical
decision making. Should this be coded as a 99212 or 99213, using exam and MDM as the
components for choosing the level? A: I don’t remember, but I think my answer
was kind of lengthy on this one… Well, evidently it wasn’t very lengthy. Laureen: [Laughter] Tammy: Maybe in my mind, it was very lengthy
to do that. First of all, not every auditor will audit
a chart exactly the same way. So, the question I guess is
from inside your office discussing it or amongst other auditors, and not every auditor will
say something the exact same way. It doesn’t mean that we’re not following the rules,
it just means that there are those gray areas, like you mentioned, where you make a case
for one side or the other. So, what you may feel is a 99212, I may feel as a 99213. You didn’t include the diagnosis with your
question, I’m assuming it isn’t earache, probably the
patient had an ear infection. So just based on the documentation you provided, yes I would
code the 99213 because he met those components that warranted a 99213. Without seeing all
of the documentation, I don’t know what the reason would be to do a down code, why
you would go to a 99212. I think maybe it was the medical decision making that someone
may feel that they need to go do a 99212 that you don’t feel that it should have been
moderate, that it should have been low since all we did was write a script. But if you
follow your auditing charts, writing a prescription is considered to be a moderate level; so based
on this what you gave me, I would agree with a 99213 on that. Another thing that I feel, like, documentation
and exam and medical decision making has to be really, really bad for me to do a down
code, to a 99212. Sometimes, it’s warranted and I know that an ear infection doesn’t
sound like much, but if you’re giving a patient an antibiotic, you do have things
that you need to consider there for doing that. I hope I answered your question; if
not, let me know. Alicia: That’s right. You can add questions
to the question box, if you have anything additional that you want to ask Tammy and
she will be able to answer them at the end. Yey! Thank you, Tammy. Tammy: You’re welcome. Alicia: Another poll. Tammy: I know what credential I want next. Alicia: What is it? Tammy: I want my CRC. I am getting my CRC,
and then, that’s it, I’m retiring.

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