Notes and billing

[da8s0859q]

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Looking to clarify something billing type questions I have and how this affects reimbursement.

Epic with Dragon where I am as well as where I'll be as an attending in July. My reimbursement will be, in part, productivity based on fees billed.

Looking to make sure I'm "doing it right." As is, I try to hit the minimum four HPI elements, have the ROS so as to not downcode an otherwise 99285, same for a PE.

The MDM and final diagnosis list in Epic is what I'm looking to make sure. Aware of tables which talk about complexity of decision-making, studies ordered/reviewed, etc, but trying to make sure I'm not leaving something out.

What habits should I make sure I'm in so as to have an appropriate MDM so as to not be downcoded when a higher chart is appropriate? Does reimbursement change with listing incidental findings, like that low mag, the kidney disease unrelated to ED visit, etc?

 

[The White Coat Investor]

Not really. Make sure you have a differential diagnosis in every chart. Include stuff that will kill you for dyspnea, AMS, abd pain, belly pain. Order enough tests. Write down your diagnoses and plan. Charts generally get downgraded for missing ROS and PE. Rarely for HPI and PFSH. Very rarely for MDM.

 

[Old_Mil]

I am assuming that Epic, like Cerner, offers both chief complaint specific templates and real time auto levelling of the chart by the computer. What I would do is create a test chart and start playing around with it in the template to see how adding and skipping various elements affect the level of the chart.