Medicare Compliance & Reimbursement

Show physicians how to thoroughly document all diagnoses addressed to ensure complete documentation. If your physician sees a large number of patients who have complex cases with multiple diagnoses, selecting an appropriate E/M level might be a challenge. However, once you take the coexisting conditions and the amount of time spent counseling the patient into account, you should be able to see the whole picture -- and you may justify selecting a higher E/M level than you thought. The key? Show your physicians how to thoroughly document every condition they evaluate, and not just the presenting complaint. Checking for Coexisting Conditions As physicians know, coexisting conditions may not be immediately apparent and often are discovered during the history-taking component of the initial patient encounter. The information about coexisting conditions may come from the patient, the patient's family, or previous medical documentation. Within the entire history component of an E/M visit, there [...]