Proper reimbursement hinges on providers telling the whole story of their encounters with patients. Documentation is key to reimbursement. The more detailed it is, the more likely you’ll receive proper payment for the service it describes. When it comes to evaluation and management services (E/M), every encounter must have a beginning, middle, and end. Unfortunately, ...
In Audit
May 17th, 2016
A few weeks ago, while on a road trip, I was catching up on some podcasts. One caught my attention because of its simplicity and the ability to apply the logic to so many real life events. In this particular program there was an interview with a professor at Cornell University who, in 1999, along ...
In Billing
Feb 19th, 2016
When billing Medicare, a provider may use either the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services to document their choice of evaluation and management (E/M) CPT or HCPCS Level II code. For services performed on or after September 10, 2013, however, physicians may use the 1997 documentation guidelines for an extended history of present illness ...
In Audit
Jul 15th, 2015
by John Verhovshek, MA, CPC Medical necessity is demonstrated based on information captured in the history of present illness (HPI). Documentation quality matters more than quantity. The information should be relevant to the presenting problem(s), and it should seek to answer the questions each HPI element asks, as follows: Location: e.g., Back pain, Nasal Congestion ...
Apr 23rd, 2015
By Jaci Johnson-Kipreos, CPC, COC, CPMA, CPC-I, CEMC When asked to conduct an audit focusing on Evaluation and Management (E/M) codes, what level of detail should the report provide? The spreadsheet, at a minimum, should have a way to identify the patient, date of service, provider of care, and codes that were billed. If there ...