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 ...
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. ...
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 ...
Apr 1st, 2013
By Ronda Tews, CPC, CHC, CCS-P Most emergency department (ED) visits are stressful for the patient, but too often they are also stressful for the coder or physician responsible for choosing the evaluation and management (E/M) level to report to the payer. At first glance, choosing a service level shouldn’t be hard: There are only ...