Who Damaged You?

Featured coffee – Caramel Apple

I recently met with a coder to review her audit findings.  She is an experienced coder, but this was the first time I was asked to audit her.

I was impressed with her coding skills.  She accurately coded some of the most complicated cases, and she was able to translate some of the most flawed documentation.

I did not fail any of her records, but I met with her to discuss opportunities for provider documentation improvement training.

When she walked in, she saw the first note that I had open, and before I could say anything, she became defensive.

Each time I tried to get a word in, she cut me off!

I tried to tell her that I agreed with her coding, but she could not hear anything.

My first thought was that she had anger issues (don’t forget, this is my opportunity to share what’s “inside the mind of a medical coding auditor”).  My knee jerk reaction was to end the meeting and move on to another coder who also scored well on her audit.

Instead, I listened to her.  I allowed her to be heard.

I was finally able to explain that I was meeting with her because she expertly abstracted a complex record.  I wanted to know if she was interested in meeting with the physicians to conduct documentation improvement training sessions.

She apologized for her outburst and explained that she has never received positive feedback.  The only communication she received was when records failed.

I know we are all busy, but the same way we schedule a time to meet with coders to discuss negative findings, let’s commit to scheduling time to meet with coders to acknowledge their positive results.

 

Tuesday, September 29^th, is National Coffee Day!

 

 

 

Guest Blogger Post – Jennifer’s Journey

Featured coffee – Pecan Torte

I’m sharing a post by guest blogger, Jennifer.

If you would like to share your story, feel free to contact me at diaryofamedicalcodingauditor@gmail.com.

Feel free to like, share, and leave your comments below.

Early in my career, I worked as a member of a coding team at a large hospital.   

I was not looking to make friends, but I did expect to earn my place as part of the team.

 But that didn’t happen. 

 The coding manager had a few obvious favorites. If you were not included in that circle, it didn’t matter how high your coding accuracy or production was. There was always something else to criticize. 

 Years later, since I’ve become a coding manager, I am conscientious about making sure all members of my team know how important they are to the success of the team.

 I lead by being a positive example, I communicate openly, and I set aside time each week for group discussions.

Reader’s Questions – Legacy MDM

Featured coffee – Tiramisu Parfaits

I received the following coding question:

Using the current E/M coding guidelines, under data reviewed for labs, medicine tests, and radiology, I was told only one for each category regardless of how many are reviewed or ordered.  According to one of my providers, I should count the total number of tests reviewed or ordered.  For example, if my provider documents orders for an x-ray and a CT scan, I should count as two, not one for the CPT category.

Who is correct?

You are correct, and here are some resources you can share with your provider.

According to the E/M Scoresheet on your Medicare carrier’s (Novitas Solutions) website, Amount and/or Complexity of Data Reviewed, points are already assigned on the Scoresheet.

Review and/or order of clinical lab tests	1
Review and/or order of tests in the radiology section of CPT	1
Review and/or order of tests in the medicine section of CPT	1
Discussion of test results with performing physician	1
Decision to obtain old records and/or obtain history from someone other than patient	1
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider	2
Independent visualization of image, tracing or specimen itself (not simply review of report)	2

Coders are instructed, “For each category of reviewed data identified, circle the number in the points column. Total the points”.

There’s also a FAQ that provides clarification.

If you have a question, please feel free to email me:  diaryofamedicalcodingauditor@gmail.com.