Medicare Compliance & Reimbursement

Escape scrutiny — and ensure proper payment — with specific body part descriptions.

If you want to avoid coming under the microscope during audits and OIG reviews, then you must clean up your doctor’s E/M documentation act. To get the credit for the exam the physician performed, it is vital that the E/M notes are clear cut and mention organ systems rather than generalized body parts.

The problem: Many doctors will write "abdomen" instead of "gastrointestinal tract" or even just "GI." The patient’s abdomen isn’t an organ system for purposes of the physical exam portion of the E/M visit, but the GI tract is, say experts. So your doctor may lose credit for examining the patient’s GI tract. At the very least, it doesn’t sound as if your doctor performed a thorough examination of the GI tract.

Also, many doctors will write "head" when they examined the patient’s eyes as well as the patient’s ear, nose and throat. Eyes count as one organ system, and so do ENT. But if the doctor merely writes "head," he or she will receive credit for one body part instead of two organ systems — or no credit at all.

If they’re supposed to be documenting organ systems and they’re documenting body sites, then auditors could knock those claims down. Auditors will be looking for documentation that doesn’t support the level of service you claimed.

Tip: You should use a template to make sure your doctor documents the correct organ systems instead of body parts. This can be a paper checklist or an electronic record.