Emr

Just started. Having trouble getting a level 4 new patient office. It's in medical decision making. Any advice on what to document?

Sep 6th, 2012 - Codapedia Editor 1,399

re: EMR

Level four new patient visit requires:

Comprehensive history
Comprehensive exam
Moderate MDM

New problem with prescription drug management
Undiagnosed new problem with uncertain outcome

In my experience, it is usually the history or exam that keeps a new patient from being a level four. Is your EMR doing the coding?

Sep 6th, 2012 - rphelps 615 1

re: EMR

Yes it is calculating the code. The hx and exam are comprehensive.

Sep 6th, 2012 - Codapedia Editor 1,399

re: EMR

I think some EMR programs don't accurately assess MDM. They may credit new problems as established or vice versa. The table of risk isn't always easy to assess by a program.

Can you give us some examples of cases (the diagnosis and plan) of visits that the EMR is auditing as 99203?

Sep 7th, 2012 - rphelps 615 1

re: EMR

G ulcer,hep c,cron liver dz,diabetes. Plan: ordered labs, ultrasound, scheduled endoscopy and esophageal dilation.