E/M Auditing Specialty Providers

So I wanted to talk about something that has come up for me lately, and also I was reading about this in a NAMUS article, and also I've, I've had some conversations with other auditors when it comes to auditing E&M visits.

And then I get a lot of questions saying, "Well, I have a specific specialty and the guidelines really s- say this," or, you know, "I'm urology and it says this," or, "I'm cardiology and it says this." And, you know, this is a topic that I am definitely passionate about being a specialty coder and auditor.

But I wanted to just talk about this for a second because I think there's some conflicting opinions out there.

Well, I know there are.

And I think that we, we have to have a conversation about it.

So let me, let me just get into it.

So, you know, I hear a lot of times, mostly from providers, that an, um, an E&M auditor needs to specialize in certain specialties before they can audit E&M services, and I understand where that comes from.

You know, it, it absolutely helps you as a, as an auditor.

I know it helps me, because many of you know I have a clinical background.

Not a prax- practicing RN anymore, but that's definitely helps in my auditing, uh, scope.

But you need to be familiar with anatomy, medications, terminology and, you know, common treatment plans within that specialty that you're auditing, of course.

That knowledge can make the note easier to follow.

It can also help the auditor know when they need to ask a specific question or if they need to find specific research.

Remember, for example, okay, when I see somebody is diabetic, but again, I want the physician to link the diabetes to their management, there's a possibility that there could be a slower healing process if they have surgery or if they have fracture care or if they have anything going on.

And chronic conditions, especially ones that are may not be controlled, uh, can have an impact on management of other services.

It's kind of like put yourself in a, in a car and if you have a flat tire behind you, what does the rest of the car do? It starts to, you know, bumble away and it gets out of alignment, and then you've got the axle that possibly could break.

You know, one- once...

The body's like that, too.

If you've got some parts that aren't working, you overcompensate or the body overcompensates in other areas and it can be a problem.

And so that's what we try to get the doctors to explain to us, the providers, with their thought processes in the E&M documentation and let us know what is possibly linked, what can impact their medical decision-making because we know that MDM is about risk, risk of complications, risk of management, risk of morbidity, morbidity and mortality on the patient.

But we don't always get that, uh, within the note, and sometimes we try to make those assumptions which we can't because we have to have the physician do it.

We can't, you know, lead it that, that way.

So the important lesson here, and, and this is where we have to be clear, the E&M guidelines don't change based on specialty from a, from an 80% generic standpoint.

So for example, cardiology doesn't have one set of E&M guidelines while orthopedic, pediatrics and family medicine have another.

Now, in the CPT book, in the AMA guidelines, the required, and I do say required, um, exam based on their presenting problem may be specialty dri- driven, of course, but the medical decision-making framework still remains the sta- the same.