Improving Efficiency

[Mushdoc]

I think most docs document way too much on patients with clear diagnoses that are being admitted. Appy or chole or DKA? You know what the diagnosis is, they're being admitted and treated. Just make sure you hit your basic HPI/PE/ROS and MDM for level 5 billing. You really only need to document thinking on the patients you are sending home with higher risk and want med-mal protection, or the patients being admitted with lots of diagnostic uncertainty.

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[southerndoc]

I think most docs document way too much on patients with clear diagnoses that are being admitted. Appy or chole or DKA? You know what the diagnosis is, they're being admitted and treated. Just make sure you hit your basic HPI/PE/ROS and MDM for level 5 billing. You really only need to document thinking on the patients you are sending home with higher risk and want med-mal protection, or the patients being admitted with lots of diagnostic uncertainty.

Keep in mind that CMS and most payers will be transitioning to more MDM to support level 5 instead of just HPI/ROS/PE.

 

[thegenius]

Keep in mind that CMS and most payers will be transitioning to more MDM to support level 5 instead of just HPI/ROS/PE.

When will the day come that our MDM will be the only part of the documentation that matters? Honestly a 3-4 sentence paragraph is all that matters. Nothing else does.

 

[Dr Mantis Toboggan]

If only.

When will the day come that our MDM will be the only part of the documentation that matters? Honestly a 3-4 sentence paragraph is all that matters. Nothing else does.

 

[RustedFox]

When will the day come that our MDM will be the only part of the documentation that matters? Honestly a 3-4 sentence paragraph is all that matters. Nothing else does.

ROS is the most bogus of all.

 

[Jabbed]

ROS is the most bogus of all.

Heaven forbid you don’t ask your head trauma patient if they’re having vaginal discharge.

 

[kidthor]

Heaven forbid you don’t ask your head trauma patient if they’re having vaginal discharge.

Are they up to date on their MMR?

 

[Apollyon]

Are they up to date on their MMR?

You monster!!

 

[VA Hopeful Dr]

When will the day come that our MDM will be the only part of the documentation that matters? Honestly a 3-4 sentence paragraph is all that matters. Nothing else does.

The new CMS rules that came out last year for outpatient E&M is pretty much that. You have to have an HPI but there are no rules about how detailed it must be. ROS and PE don't affect billing at all anymore.

Wouldn't be surprised if hospital/ED codes follow suit before too much longer.

 

[Boatswain2PA]

12) Ask the pan-positive review of systems patients, "What is your worst symptom?"

Thanks for this little tidbit

The only nickle-and-dime I do is I order a BMP instead of CMP, since our lab's CMP takes FOREVER, thereby delaying CT scan waiting for the GFR.

We got rapid creatinine, which comes back before the CMP about half of the time.