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Explore This IssueApril 2012
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1. D: Medical decision making is what drives the visit and supports the medical necessity of the visit. Without medical necessity, there is no reason for the visit.
2. B: False. A chief complaint is the medical reason for the visit and should be clearly stated in the notes; therefore, a follow-up visit requires description in the notes. For example, “follow-up visit for osteoarthritis,” or “follow-up visit for rheumatoid arthritis with complications.”
3. B: Medical decision making is based on a point system. Two stable problems equal a total of two points, equating to a limited level for the number of diagnoses.
4. D: Cloned notes allow you to cut and paste notes from one visit to another. This documentation option for physicians using EHRs puts physicians at risk for audits. See this month’s article titled, “The Good and Bad of Cloned Notes” for more on cloned notes.
5. B: False. In the end, it is the physician’s responsibility to ensure that all services billed out are supported by the correct documentation in the patient’s chart. If an EHR clones the notes and chooses a code that does not support the level of medical necessity, the physician is liable and can be audited.