Ritecode.com Physician Coding Audit Report - Summary Statistics
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1 Clinic Name: 1111 Manager: 1111 OB/GYN Physician: 1111 Encounters Correct (%): 80.00% Medical Decision Making Correct (%): 80.00% Exam Correct (%): 80.00% History Correct (%): % Documentation Needs Improvement (%): 60.00% Doctor Upcoded (%): 0.00% Overall the notes are good. There are some areas of refinement or improvement recommended in both the Hx and Exam sections. Page 1 of 13
2 Clinic Name: 1112 Manager: 1112 OB/GYN Physician: 1112 Encounters Correct (%): % History Correct (%): % Documentation Needs Improvement (%): 60.00% Doctor Upcoded (%): 0.00% Recommend across the board training on every element of E & M and documentation. Most errors can be fixed in less than 30 minutes. The same errors are made in every note. Just because a note was audited correct does not mean it cannot be improved significantly. There are many types of auditors and audits. Many of the notes required significant interpretation and allowances to allow the level of visit. It is best to be sure every element is meeting requirements. Page 2 of 13
3 Clinic Name: 1113 Manager: 1113 OB/GYN Physician: 1113 Encounters Correct (%): 40.00% Medical Decision Making Correct (%): 60.00% Exam Correct (%): 60.00% History Correct (%): 20.00% Documentation Needs Improvement (%): 80.00% Doctor Upcoded (%): 0.00% Even low level encounters still require a CC, HPI, ROS, Exam and assessment or MDM. F/U for labs or discussion of treatment options is not sufficient for the Hx or Exam portion. Time could be used if only counseling is taking place - document two times - total time and counseling time (over 50% of total time). Recommend using the excellent form for every level visit and be sure to fill out to meet each level. Include a relevant CC for every visit. Page 3 of 13
4 Clinic Name: 1114 Manager: 1114 Hospitalist Physician: 1114 Encounters Correct (%): 40.00% Medical Decision Making Correct (%): 40.00% History Correct (%): % Documentation Needs Improvement (%): 80.00% Doctor Upcoded (%): 60.00% Overall good documentation. But DOS mismatches with the record and the billed CPT code. summarizing the initial and the subsequent service which is inappropriate, Recommend training on doc requirements for Comp Exam and moderate and HIGH MDM. Page 4 of 13
5 Clinic Name: 1218 Manager: 1218 Hospitalist Physician: 1218 Encounters Correct (%): % Exam Correct (%): 40.00% History Correct (%): % Documentation Needs Improvement (%): 80.00% Doctor Upcoded (%): 0.00% Very comprehensive Doco, however, Recommend Exam Training to meet the req of Good Hx and MDM. Page 5 of 13
6 Clinic Name: 1246 Manager: 1246 OB/GYN Physician: 1246 Encounters Correct (%): % History Correct (%): 80.00% Documentation Needs Improvement (%): 80.00% Doctor Upcoded (%): 0.00% Clearly the staff and Provider need overall E & M training; If there are no complaints report with well exam codes; ; CC/HPI should always reference the disease, condition or reason the pt is returning, not a lab or test or med refill. Checkup for what condition and how long? Every E & M visit regardless of level, requires CC, HPI, PFSH and ROS documented, plus correct Exam and level of MDM. Page 6 of 13
7 Clinic Name: 1258 Manager: 1258 Family Practice Physician: 1258 Encounters Correct (%): 40.00% History Correct (%): 20.00% Documentation Needs Improvement (%): 40.00% Doctor Upcoded (%): 60.00% Overall very good documentation. Recommend E & M Provider Training course on correct Hx, Exam and MDM documentation - in particular high level visits. Page 7 of 13
8 Clinic Name: 1269 Manager: 1269 Orthopedics Physician: 1269 Encounters Correct (%): % History Correct (%): 60.00% Documentation Needs Improvement (%): 80.00% Doctor Upcoded (%): 0.00% Recommend a review of detailed and Comp Exam elements; Overall good documentation. Recommend E & M Provider Training course on correct Hx, Exam and MDM documentation. Page 8 of 13
9 Clinic Name: 1280 Manager: 1280 Primary Care Physician: 1280 Encounters Correct (%): 60.00% Exam Correct (%): 80.00% History Correct (%): 40.00% Documentation Needs Improvement (%): 60.00% Doctor Upcoded (%): 20.00% Doctor Downcoded (%): 20.00% Across the board documentation can be improved. Add review of ROS and PFSH every visit; expand the Exam and improve the MDM to support Moderate MDM. Page 9 of 13
10 Clinic Name: 1329 Manager: 1329 Surgeon Group Physician: 1329 Encounters Correct (%): 60.00% Medical Decision Making Correct (%): 80.00% Exam Correct (%): 60.00% History Correct (%): 80.00% Documentation Needs Improvement (%): 20.00% Doctor Upcoded (%): 20.00% Rec follow a standard format for doc Hx, Exam and MDM. Every record must have Hx, PE and MDM doc regardless of the encounter. Page 10 of 13
11 Clinic Name: 1385 Manager: 1385 Dermatologist Physician: 1385 Encounters Correct (%): 80.00% Medical Decision Making Correct (%): 80.00% History Correct (%): % Documentation Needs Improvement (%): 20.00% Doctor Upcoded (%): 20.00% Opinions differ on the validity of MOD-25 with minor surgical procedures. While CPT does state the ICD-9 code can be the same, it is clear that the E & M encounter must be distinct and separate from the reason for the procedure. I recommend against reporting the E & M with the procedures as indicated unless the distinct and separate reason for the E & M encounter is established. Page 11 of 13
12 Clinic Name: 1400 Manager: 1400 Hospitalist Physician: 1400 Encounters Correct (%): 60.00% Medical Decision Making Correct (%): 60.00% Exam Correct (%): 80.00% History Correct (%): % Documentation Needs Improvement (%): 60.00% Doctor Upcoded (%): 40.00% Date of service not documented on any of the records. Highly recommend doc from a compliance perspective.cpt not provided for the reports sent for audit. Recommed documentinge the amount of time for the discharge. Good summarization of the hospitalization encounters provided in the discharge summary. Page 12 of 13
13 Clinic Name: 1421 Manager: 1421 PEDIATRICS Physician: 1421 Encounters Correct (%): 80.00% History Correct (%): 80.00% Documentation Needs Improvement (%): % Doctor Upcoded (%): 20.00% Be sure to review PFSH every note, Review countable Exam elements and learn how to calculate moderate and High MDM. Recommend E & M Provider Training course on correct Hx, Exam and MDM documentation. Page 13 of 13
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