#audit

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    Wiki E/M Time Coding without Supporting Documentation

    I have a provider that submits level 4 and 5 E/M codes on nearly every claim stating that he spent the relevant amount of time with the patient to support that level code. He adds the saying that more then 50% of his time was spent counseling or coordinating care for the patient. The rest of his...
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    Wiki EMR Info outside of note text

    There is some debate at the facility where I am a coder as to whether info that appears in our EMR software's print preview that is not in the note itself counts as part of a note's documentation. (Provider name, date of service, duration of visit, diagnosis, location, etc.) It has been argued...
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