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IS POINT AND CLICK ENOUGH ?


Making the best use of electronic medical records has always been a challenge and the federal government has been scrutinizing charting on many levels. The points of interest to the auditors are:

  1. Cloning a chart note to the next date of service
  2.  Problem lists being used as the billing diagnosis codes, versus only billing codes that represent the evaluation and management of the condition(s) that were considered at the time of the treatment plan
  3. Incomplete comments that may not be adequate for auditing purposes:
Examples of incomplete comments, but not limited to:

Stable                                      Improving                                            Deteriorating

No change since last seen         Compliant with treatment plan

Labs/radiology reviewed          Above / or / As above

Instead comments that speak to an auditor:

 Stable on meds

Improving since last visit May 15, 2014

No change since last seen June 3, 2013

Compliant with treatment plan for lowering blood sugars

Deteriorating, consider hospice or refer to nutrition counselor

Auxiliary services reviewed, reports are negative for…

The ease of what you see in NextGen does not mean the software is sufficient to stand scrutiny by an auditor either in house or outside. There is an honorable gap between a trained clinician and a trained auditor. Auditors respect your medical expertise, however we cannot assume or re-analyze your intent. If we, as auditors, do not see a clear and concise statement to support your choice of ICD code, we cannot support the billing for that code and may delete it from the claim.

 During our pre-screening of the patient records for the patients upcoming office visit, we reference past audit results, in house, and outside records documented on your patient. If your patient does have the condition and you are monitoring, evaluating or treating that condition… please document your findings sufficiently in NextGen encounter data (Master Im), and be sure to send all your diagnosis codes through to billing. Please consider using up to 12 diagnosis codes on your patients for complete billing exportation. You are not limited to just 4.
 
Utilize the following acronym MEAT for supportive documentation,  for compliant records:
 
Monitor / Medicate    Evaluate    Assess /Address      Treatment
also    Plan   Referral
Written by:  Leslie Fleeman, CPC. Used with permission.

 
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Location: Poway, CA, USA

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