Part B Insider (Multispecialty) Coding Alert

Published on Mon Jan 21, 2013 PDF

Gut vs. stomach vs. GI -- the differences matter.

With the OIG continuing to review claims and RAC auditors right on their heels checking your documentation, you can’t afford to maintain sloppy E/M notes. To avoid getting burned over scrutiny of your records, you should ensure that your physicians pinpoint exact locations of patients’ issues so you can count their E/M elements properly.

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.