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in a Metallica T-shirt with a red pen and an abacus. Thus, I make the notes as clear
as and easy to follow as possible. I make a concerted effort to make obvious sum-
mary statements like 54-year-olds with erectile dysfunction scheduled for penile
implant, a major procedure with risk factors given his diabetes and use of Plavix.
Do your best to restate the key words and phrases found in the risk table in your
headings and assessment and plan (major surgery, parenteral controlled sub-
stances, prescription drug management). Also label each separate section, and
make the subsections clear; don’t make the auditor dig out your ten ROS from the
body of the HPI.
A Word on Defense: Overrated
I have personally undergone several medical school compliance billing and coding
audits now – if you read carefully, you’ll know that is why I am writing this text. Of
all my audits, not once have I been told you should have billed a higher level here.
Further, not once have I heard, you know your medical decision-making was very
high level, yet your documentation met only level 3 – had you only done this in the
history, you could have billed level 4. I’ve tried to change this part of the audit sys-
tem. Thus far, audits have only told me I have done things wrong, further perpetuat-
ing the cycle of fearful billing and undercharging. There is a reason for this;
compliance has a competing goal – protecting you and the university from costly,
extensive government audits and fines. This is why institutions self-audit and default
to more conservative policies. They want a paper trail of self-policing to show to
CMS how they have found, corrected, and educated providers about their errors.
However, the auditor salary has to get paid somehow. In the end, appropriate level
billing benefits everyone.
Ambiguity in Coding and Billing: It is Out There
One of the underlying reasons for defensive billing from the compliance depart-
ment’s perspective is the fact that there is ambiguity in the billing system. There are
several phrases and/or descriptions in the official Medicare guidelines which leave
one scratching their head. Here are some examples that I struggle with:
- New problem with further work-up – We all know what a new patient is, but
what does further work-up mean? If one orders a lab or X-ray for a problem, this
seems pretty straightforward. But what if a patient comes in for an elective pro-
cedure like a vasectomy – is the future appointment for the vasectomy a work-
up? My personal opinion is yes, but I’m not really sure. - “Prescription drug management” qualifies as a level 4 risk maneuver according
to the risk table. Assuming all other parts of the note are up to snuff, does a
yearly renewal of medications count as drug management? A new script, dosing
change, and recommendation on how it should be taken to alter side effect profile
T.S. Köhler