Correct bad habits before your E/M services claims are audited. by Tim Stelma, BA, CPC, CPMA, AAPC Professional Auto-fill and self-leveling functions in electronic healthcare records (EHRs) have led to higher utilization of upper-level evaluation and management (E/M) services. This has not gone unnoticed by insurance carriers. To dodge a large take-back resulting from a ...
In Coding
Oct 3rd, 2016
Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)—so called “double dipping.” Nothing in AMA/CPT® or Centers for Medicare & Medicaid (CMS) guidelines says so, either. If an item is clearly documented, you may count it ...
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 Coding
Sep 15th, 2015
by John Verhovshek, MA, CPC Documentation stating “Family History Reviewed” is insufficient to satisfy evaluation and management (E/M) documentation requirements. Both the 1995 and 1997 documentation guidelines specify, “A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the ...
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 ...