In Audit
Mar 16th, 2015
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA In February, we examined how “labels” might cause an incorrect count of organ systems examined if an auditor doesn’t take care to read the details beyond the labels. For purposes of this discussion we will assume that the examination and complexity of MDM meet the proposed ...
Aug 8th, 2014
Clear and comprehensive documentation is a critical element in getting claims paid. You hear that advice day in and day out. So what do you do when the provider is unable to obtain a critical component of documentation from a patient? The answer isn’t as tricky as you might think. When a provider is unable ...
Knowing the risks EHRs pose is the first step to improving E/M documentation. By Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC The use of electronic health records (EHRs) is steadily increasing, and so are the number of high-level evaluation and management (E/M) services being billed. These claims may very well be substantiated by documentation contained ...
May 1st, 2013
Review the history component in your E/M documentation to make sure it tells the patient’s presenting story. By Brandi Tadlock, CPC, CPC-P, CPMA, CPCO Evaluation and management (E/M) documentation requirements are complex, but it’s imperative for documentation to meet the criteria with every encounter. This ensures high quality patient care and proper reimbursement, and protects ...
Mar 20th, 2013
By Brandi Tadlock, CPC, CPC-P, CPMA, CPCO To ensure high quality patient care and proper reimbursement, and to help protect you from audits, evaluation and management (E/M) documentation must meet or exceed complex requirements for every encounter. When it comes to determining medical necessity—the overarching criterion for payment—for E/M services, one area of provider documentation ...