tci Part B Insider - 2005 Issue 10

AUDITS: Audit-Proof Your MDM With Beefed-Up Documentation

Make providers describe the decision-making, or your audit could be a tragedy When Medicare sends auditors to look at your evaluation and management claims, they're going to zero in on your doctors' medical decision-making, experts say. Auditors aren't scrutinizing the exam or history as much - "they definitely weight [the audit] toward medical decision-making," says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, ID. The problem: Even if your physician keeps spotless records of history and exam, you could find yourself downcoding or facing audits if the medical decision-making doesn't tell a good...

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