After completing focused audits on the 2021 Evaluation and Management MDM changes, I met with a group of coders.
The audit results and the feedback from the coders were concerning.
Are you sure you’re staying up to date on the changes in MDM?
Only 40% of the coders scored over 90% in the audits.
The failures were due to the coders not correctly translating MDM according to AMA’s revisions.
Some were not aware of AMA’s FAQ page. This is a valuable source for clarification. Are you correctly translating MDM?
According to AMA:
Coders “should not determine whether a patient’s medical problem or illness is stable or worsening.”
Providers are responsible for clearly documenting the status of the condition.
The distinction between minor surgery and major surgery is not based on the global period assigned to the surgical procedure code.
“The physician or QHP who evaluates the patient is the best judge of the specific patient factors that make a procedure “high risk” for a patient. Every surgical procedure carries some element of risk; however, a relatively simple procedure for an otherwise healthy adult carries a different level of risk than the level of risk for an older patient with multiple comorbidities.”
The provider must document whether the procedure is major or minor.
So, whether or not there’s a webinar that offers CEU’s, coders are responsible for staying up to date on coding and industry changes.
We’re responsible for our coding accuracy and providing accurate feedback to our physicians.
Coffee With a Medical Coding Auditor 