You want the provider to know what he or she did right on these records, and to keep documenting this way.Įxplain how the provider correctly documented the necessary elements for history, exam, and medical decision-making (MDM), based on the documentation guidelines. Second, the “why” for passing an audit is as important as the “why” for not passing an audit. If you start with the “passing” records first, it starts the meeting off in a positive way. “Several notes were of excellent quality.”Īfter you make the general “pass/fail” statement, explain why the physician passed, or didn’t, and then drill down to the actual results.Open your meeting with a statement such as, “I’m here to educate you on the findings of your chart review,” followed by a general and positive statement, for example: It’s also important to bring copies of the 19 audit guidelines with you, plus any special audit rules or regulations from your Medicare intermediary. The curve is a good tool to help select providers and charts to audit. Each provider should have a bell curve done every year. A bell curve shows physicians how they are coding, relative to their peers. To provide more detail, break down your findings into an encounter detail report, as shown in. Make sure you have provided enough information in the summary for you to explain fully any notes that did not correspond in the audit to the code selected by the provider. I use “pass” and either “not supported by documentation” or “supported at a different level than selected.” These tend to get the message across, but don’t put the provider on the defensive. When reporting results and meeting with provider, don’t use the word “failed” because this gives a negative impression. In addition to the basic information, a great report should include summary notes and findings. Providers’ records will not look the same.) All three key components support the lower level. ![]() The CC and HPI are related to HTN–ROS and Exam only address areas related to the HTN.ĭocumentation supports a lower level of service than selected by provider. All three of the key components support a lower level of service. ![]() It should only be used when a routine examination or counseling is performed.ĭocumentation does not support the level of service selected by the provider. The history level and the MDM both supported the higher level of service. Per 1997 guidelines – the status of three chronic conditions – extended HPI.
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