Follow best practices to meet annual exam documentation requirements. By Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC, CSCG, AAPC Fellow Unlike other evaluation and management (E/M) services in the CPT® codebook, preventive services do not have specific documentation guidelines required to support the service provided. Here’s what you should know to ensure documentation supports ...
Ensure your home visits are medically necessary and meet payer billing requirements. By Beth Schleeper, COC, CPC, CPB, CPCO, CPMA, CPPM, CPC-I, CEMC, AAPC Fellow As a patient, having a physician come to your home to treat you while you are ill is a blessing. As a coder, reporting such a visit can be tricky. ...
Arm against fraud risks EHRs pose, and develop policies to reinforce compliance. Electronic health records (EHRs) make documentation more legible, but they also make it easier to inflate content. Evaluation and management (E/M) documentation is especially prone to EHR shortcomings because of the repetitive nature of these services. Let’s consider the risks and resolutions. Authenticate ...
The medical decision-making (MDM) component of evaluation and management (E/M) services is perhaps the most crucial element in determining the correct level of service assignment for patient encounters. The majority of individuals involved in the E/M coding process may not agree on the interpretation of the components, but would agree that the clinical thought process ...
Payer rules differ with what’s considered an unrelated E/M service provided during the global period of a procedure. Typically, an evaluation and management (E/M) service provided during the global period of a procedure is not separately reimbursed, but is bundled into payment for the procedure. An exception occurs when the E/M service is unrelated to ...