Dispute regarding an E&M visit note with Terry Fletcher | Coding | Auditing | E/M
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- Опубліковано 14 лис 2023
- Dr. John Lin shares his perspective on why a particular visit is a 99214 and not a 99213, despite what a well-known and respected auditor may feel. Medical decision making, prescription drug management, data, time-based billing relative to medical evaluation and management coding are mentioned in this video.
Urology-specific prescription drug management in medical decision making relative to coding video:
• Prescription Drug Mana...
Terry Fletcher:
www.terryfletcher.net/
Her podcast under discussion:
• E/M Leveling with MDM:...
E/M University:
emuniversity.com/
E/M University Coding Rounds and explanation mentioned in the video:
emuniversity.com/COW/case_102...
John C. Lin, MD, works at Sunrise Urology. He is a frequent presenter on matters related to efficient practice management, coding, billing, marketing, and online reputation management.
http//www.SunriseUrology.com
The Thriving Urology Practice Facebook Group:
/ thrivingpractice
#Coding #E&M #Auditing
Wow! Where I code unless the physician changes medication, increase or decrease dosage etc it is considered low.
When appropriate documentation is present to demonstrate prescription drug management,
1. Starting a medication
2. Stopping a medication
3. Continuing a medicatiion
4. Providing a sample
all constitute management.
Just listened to this and totally agree with you. Would it be nice to have documentation as stated in the email exchange, yes. But not real world, it is our job as coders/auditors to understand the information in the notes.
I appreciate your insights and perspective.
This would very clearly be a 99213 for my latest E/M audit client: 2 stable chronic conditions with OTC drug management. Let me explain: this client (or rather their MAC) required that medications have dosages specified during rx drug management. Without that the drug can only be counted as OTC (even in cases like this where the drug is obviously Rx).
If we just go by AMA rules, then 'technically' we can defend a 99214, but only because the AMA is incredibly vague in their expectations. I see why Terry would not want to go there. I also agree with her that this visit was probably not 25 minutes. My guess is that the provider documented total time for lab reviews, charting and everything.
This is one of those notes where the provider performed more work in their head than on paper.
I am sure in the real life documentation, the drug name, dose, route of adminstration, quantity, and refills are all listed in the EHR. It's just not stated in the example given.
Aside: Most of our problems involve NOT documenting the Rx drug MANAGEMENT. As I clearly discussed in another video, simply listing a med in the EHR is NOT prescription drug management.
ua-cam.com/video/MARrd0HNT6M/v-deo.html
Rx drug management is NOT the issue here...
😊 Thanks
My pleasure!
I love Terry however I agree with you.
Logic trumps feelings.
I too, like Terry. Literally said it in my video.