"Discussion Of Case With Another Health Care Provider" and CMS Definition of Health Care Provider

Trying to code every evaluation and management (E/M) visit correctly, every time, is difficult. Why? Because Medicare, by default, established rules which were vague and open to interpretation. While not a product of CMS, the Marshfield Clinic audit tool is used by many Medicare carriers to help define the medical decision making component of the E/M rules as low, medium or high. These rules are complicated. After a decade, I still use a bedside E/M reference card I created as a reference to try and help me get my correct level of care every time.

In the medical decision making (MDM) component of E/M coding there are  three  components, the highest two of which determine the overall MDM.  These are the diagnosis, data and risk.  Within the data component includes the statement
Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider
 If you document "discussion of  case with another health care provider" this documentation will provide you with 2 points in the data section of medical decision making. If you call up the GI doctor and tell him about the new consult or if you call the PCP to talk about aspects of the pateint's care, remember to document that you had this discussion and what you discussed and the Marshfield Clinic audit tool will give you two points in the data section of medical decision making.  Under coding is also fraud.

No where could I find a definition of exactly how in depth your documentation has to be to qualify for these two points in the MDM data section.  I usually document that I discussed "case details".  Here is a discussion of this very question from a coding forum in 2011.  Again, notice how vague the rule is and why so much of E/M documentation is open to interpretation.  One coder may give credit while another may not.  In addition, one CMS auditor may give credit while another may not.  These vague rules often cause physicians to under code in fear of getting a CMS audit of their E/M charges.

In addition, I think it's important to define who a health care provider is for the purposes of meeting the documentation requirements.  If I call the microbiology lab and ask to speak with a lab tech regarding blood cultures, can I get 2 points of credit for my data in the MDM?  If I spoke with the respiratory therapist or the nurse regarding patient care issues, and I document my discussion in my progress note, can I get 2 points for discussion of case with another health care provider?

What better way to make sure you're compliant than to go to the CMS website and find their definition of health care provider.  In the CMS glossary site, you'll find their exact definition of a health care provider:
A person who is trained and licensed to give health care. Also, a place that is licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers.
I have no doubt in my mind that speaking with doctors, nurses,  RTs, PTs, OTs, cardiovascular and radiology technologists and any of many other trained and licensed persons I come in contact with every day and documenting my discussion with them in my note will allow me 2 points in the data section of MDM.  I note also that hospitals are considered health care providers.  This is a bit odd to me to call buildings a provider.  But, apparently, CMS defines a hospital as a provider.  Would calling the microbiology lab tech and asking for updated culture results allow me 2 points in the data component of MDM?  Using my interpretation of defining hospitals as a health care provider, I would say yes.  These folks are all trained in their jobs to deliver health care in a place that is licensed to give health care and since CMS defines hospitals as a health care provider, all these folks involved in the delivery of health care in a hospital should count if I discuss patient care and document that I did indeed speak with them.

These two points of medically necessary interaction can make the difference between meeting the criteria for a level two hospital follow up or admission or a level three hospital follow up or admission.  I think most doctors under-appreciate the power of understanding how to document for work provided and how this documentation can support higher levels of care that are not currently being billed and which ultimately skew the bell curve to lower levels of care when, in fact, a higher level of service is being provided if doctors would just document their work provided.

I bet most  hospitalists  will discuss the case with the ER physician when they are asked to admit a patient.  Document this discussion and you can obtain two points in the data component of medical decision making for discussion of case with another health care provider.  Did you discuss a patient with the nocturnist or the night shift hospitalist in your morning  hand off?    Document your discussion and you can get those two critically important points toward your data component for MDM.  Those two points can make the difference in your E/M coding.  If you aren't documenting these discussions and you're under billing as a result, you are committing fraud, although I can assure you no one is going to be knocking on your door to pay you money you are due.



EM Pocket Reference Cards Using Marshfield Clinic Point Audit



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