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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.

Medical Coding Auditor Training | Earache Question – Video

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 among st 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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2016-11-20T23:37:03+00:00

About the Author:

Laureen Jandroep
CPC, COC, CPPM, CPC-I.,Sr. Instructor for CCO.us. Resides in southern New Jersey with her husband of over 20 years Anthony and four children. They are active parents and spend most of their time these days just being parents which they love.

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