tci ED Coding & Reimbursement Alert - 1998 Issue 1

Four Quick Documentation Strategies to Satisfy E/M Guidelines

Despite the confusion over the implementation of the 1997 Evaluation and Management (E/M) Guidelines, EDs must still adhere to either the 1995 or 1997 version. The 1995 guidelines are considered most beneficial to emergency medicine. Here are some key tips to ensure ED physicians are providing the right documentation to justify the appropriate level of service. Remind ED physicians to document vital signs, orders, ED course, critical care time in dictations. (Coders dont always get the nurses notes.) For templated records, review for consistency and accuracy in how templates are used. Routinely communicate problems to physicians until resolved. Provide...

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