Have you ever had one of those questions that you think you have the answer to, but the more you read it, the more you’re swayed the other way — and then you read it again and you have an even different answer? Well, one of our NAMAS members (and a friend of mine) emailed such a question this week, and as a matter of fact, she gave me four different variations of that question. So, I thought I’d share her question on external source with all of you.
Before we dig in, let’s read the definition of “external” according to the 2021 documentation guidelines:
“An external physician or QHP who is not in the same group practice or is of a different specialty or even subspecialty. This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider, such as from a hospital, nursing facility or home health care agency”.
Now, that definition seems pretty comprehensive, but when we take it into our everyday practice, especially into large health systems as many of you belong, it becomes a little bit convoluted and hard to work with. So, let’s get to our first (and easiest) question:
There are three providers in a pediactric nephrology clinic. The primary taxonomy for one of the providers is Pediatrics. The other two providers have a primary taxonomy of Pediatric Nephrology. All three providers are giving the same care and will often cover for the others. So, when they’re covering for the others and they’re reviewing the notes, can we consider this review of external notes?
One of the things we have to consider here is your immediate knee-jerk reaction (and maybe what mine was too). Well…we’re covering for the other group. On the one hand, you want to say no, you can not consider this because that’s part of what you do when you’re covering for another group. But, on the other hand, they are members of a different group because they are different subspecialties and there is a risk in caring for someone of a different group. They do have to review those notes to become better acquainted with that patient to provide the appropriate care, and that is what review of external notes allows that risk component for. There’s the intent we’ve been talking about for the past couple of weeks*. There’s the intent of what the rule was made for and the mechanics of what it’s made for — and that’s exactly what it falls on here. An internal policy is needed here on how your organization is going to address this. As a coder and auditor, we seek to know what the right answer is, and again, there’s no published guidance on what the right answer is. Best practice here is…audit your note. I don’t think this is going to make the difference between one level of service or the other. If it truly is going to make a difference between one level of service or another, then your organization should have a policy that says if you audit the note, and this is going to be the determining factor in making the difference between a Level 3 or level 4, a Level 4 or a level 5, then at that point, this [fill in the policy decision here] is the decision making that we put in place for how to proceed on that given encounter.
Here’s our next question, and I’ll be honest here…this was the note that finally had me really wanting to pull my hair out;
In many primary care clinics, there are specialties of internal medicine, family medicine, and pediatric internal medicine and they will occasionally see patients depending upon availability for each other. Again, we have these subspecialists seeing each other’s patients, but they have to review those external notes because they’re different specialties. So how do we consider those in our everyday practice when we’re auditing and coding those notes?
I go back and tell you the intent, the technicality of the rule, is they are different specialties. They are members of the same group, but different specialties, and the technical of the rule is that does count. It does count as an external notes review. Yes, there was part of me that was going to say, “Well, I don’t know if we should allow that”, but the other part of me says… ”but again, they’re seeing the patient they’ve never seen before for a problem they’ve never seen before, so that’s higher risk”. You must consider all of those. This is the intent.
Again, I encourage you to sit down with your compliance department, sit down with the medical director of the department, and have a true-up conversation about how this should be handled moving forward in the decision-making process of scoring the MDM for that middle column. Our middle column has a lot of different presentations, and this is just another one of those. It is tricky and certainly needs an internal policy for your organization.
* Read previous posts on The Mechanics vs. the Intent of the Code and Addendums and watch videos about these topics on the NAMAS YouTube Channel
