Apr 1st, 2013
By Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS As a physician auditor, I spend much of my time educating clinicians on proper documentation. This involves explaining and interpreting coding and compliance guidelines. When providing such guidance, the most common reply I hear from providers is, “I want it in writing.” An auditing ...
In Audit
Oct 6th, 2010
By Pam Brooks, CPC, PCS The question, “What constitutes a detailed examination in the 1995 Documentation Guidelines for Evaluation and Management Services?” conjures up ambiguous responses regarding evaluation and management (E/M) documentation criteria. For detail-oriented coders, this gray area is responsible for lengthy discussions, confusion, and occasional misinterpretation—because there is no...