tci Part B Insider - 2004 Issue 23

Carrier Lists MDM Mistakes

Part B carrier National Heritage Insurance Co. lists problems with medical decision making documentation that its medical review staff has found. They include: The records showed MDM but lacked specific information. The patient plan of care wasn't clearly documented. The details of the MDM were illegible. The complexity of issues and management options weren't clearly described. The MDM was documented, but wasn't to be found in one clearly identifiable area on the medical record. The physician failed to document all the diagnoses he/she considered during evaluation of the patient. ...

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