Auditing Issues Uncovered in Physician Documentation: Part IV

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor

Editor’s Note: This is the final installment in a four-part series that examines physician documentation issues as seen by an auditor.

Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I
Click here to read part two: Auditing Issues Uncovered in Physician Documentation: Part II
Click here to read part three: Auditing Issues Uncovered in Physician Documentation: Part III

In the last installment of this four-part series, I want to discuss the importance an auditor puts on the medical decision-making (MDM) portion of the evaluation and management (E&M) record. According to the Centers for Medicare & Medicaid Services (CMS), this constitutes the overarching criteria that drive the visit code – meaning that it is perceived as having more weight than the history and exam portion of the encounter.

However, the MDM is not the only factor in choosing a level of service. Again, as the overarching criteria, it is necessary to understand the thought process, not to mention the scoring process, of an auditor, especially when providers are trying not only to determine their final level of service, but also how to pass an audit.