stay informed 2 Vaccines are in the news, on social media, and in the dinner table conversation. Measles is at the forefront, due to the rise in reported cases. People have their own views, beliefs, and concerns regarding vaccines. That is where the physician comes into play. You are the qualified professional who can best provide accurate information about vaccinations and meet your patients’ medical needs. Texas Health Steps requires an immunization record review at every visit. Are they up-to-date? Are they missing an immunization? Are they scheduled to receive an immunization soon? Each visit to your office is an opportunity for this review. A quick conversation with parents and / or the patient can often provide answers and alleviate any doubts they may have. Distributing educational material can also provide the information that they may need. Vaccines save lives, Does your documentation support your E / M level? We know how busy your days are. Taking a moment to make sure your E / M documentation supports the level you bill can help avoid issues later. Under CPT guidelines, you may select the E / M level based on Medical Decision Making (MDM) or total time spent on the date of the encounter. MDM considers three main areas: ■Problems addressed—the number and complexity of conditions evaluated and managed. ■Data reviewed or ordered—labs, imaging, tests, or outside records. ■Risk to the patient—the risk of complications, morbidity, or mortality from management decisions. In our reviews, we often see cases where the documented MDM does not fully support the level billed. This may result in recoupment during audit review. A few simple ways to strengthen your documentation: ■Clearly describe the patient’s condition and why that level of care was needed. ■Document any labs, imaging, or outside records reviewed. ■Include key risk factors or treatment decisions, such as medication changes. ■Let your clinical thinking show so the visit level is easy to understand. If selecting the level based on time, document the total time you spent on the date of service and the work performed. Taking a moment to review your notes can go a long way in supporting accurate billing and keeping things smooth during reviews. Questions? Reach out to Provider Relations anytime. and administering them at their scheduled times is necessary for infection prevention. Not only does an immunization review ensure the safety and compliance of the member, but it may also satisfy the Childhood Immunization Status Measure for HEDIS. Several records that were reviewed for this past HEDIS season had 1 or 2 immunizations missing! When Providers review the immunization record at every visit, needed vaccines can be administered so that these children can be covered. Did you review your patient’s immunization record?
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