In Billing
Jun 9th, 2014
Evaluation and management (E/M) services comprise a significant portion of most providers’ billable services. To ensure coding (and reimbursement) reaches optimal levels, providers must be careful to document services carefully. Here are five common problem areas to watch for. 1. Legibility When it comes to coding, two fundamental rules are “Not documented, not done,” and ...
In Billing
May 19th, 2014
Question: Is it acceptable for ancillary personnel to obtain and record elements of the history of present illness (HPI) portion of the history component? Chapters 12 and 15 of the CMS web manuals do not reference the HPI—only the review of systems (ROS) and past/family/social history (PFSH). Answer: Per CMS rules and the 1995 and ...
In Billing
Mar 3rd, 2014
When evaluating documentation for the history component of an evaluation and management (E/M) service, keep in mind: A chief complaint is a medically necessary reason for the patient to be meeting with the physician. A readily identifiable chief complaint is the first step in establishing medical necessity. Without a chief complaint, the service is preventive. ...
In Audit
Sep 30th, 2013
When considering the history component of any evaluation and management (E/M) service, keep in mind the following: A chief complaint is the reason the patient feels he or she needs care. Unless the encounter is for a preventive medical history and physical, the chief complaint must be easily identifiable. This is the first step towards ...
Sep 27th, 2013
Effective Sept. 10, the Centers for Medicare & Medicaid Services (CMS) has revised its Evaluation and Management (E/M) Documentation Guidelines (DG), to allow physicians to use the 1997 DG for an extended history of present illness (HPI) with the other elements of the 1995 DG to document an E/M service. As a result, “the status ...