tci Medicare Compliance & Reimbursement - 2005 Issue 15

PHYSICIANS: To Avoid Audits, Show MDM Thought Process

Physicians can improve documentation by following these tips.A physician's operative notes may have a history and physical exam as spotless as mother's china, but if the medical decision-making (MDM) is weak, auditors can come and shatter the claims to pieces.Luckily, experts have a few suggestions to help physicians repair the medical decision-making section of their claims. Use these tips to make MDM documentation a breeze:1. List complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking or adverse reactions the patient had to previous medications, says Lori-Lynne Webb...

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