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Thread: EHR, Prompting Doctors documentation on exams

  1. #1
    Join Date
    Apr 2007

    Default EHR, Prompting Doctors documentation on exams

    AAPC: Back to School
    Can anyone tell me where there might be referrence to avoiding prompting doctors on what to document on to get a higher level of charge. We were asked if we could give the doctors clues on what would increase their CPT level at the time of the visit. I thought I read somewhere that you should not prompt the doctor while documenting
    Last edited by CRSTRADTMAN; 05-13-2011 at 12:17 PM.

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Medicare has guidance on this...

    "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."

    Page 38


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