tci ED Coding & Reimbursement Alert - 2017 Issue 3

Reader Question: Look for the Link Before Counting Resident Documentation in Your Code Selection

Question: If no linking statement by the attending is present, which part of the resident's note may be used in levelling an E/M service for a Medicare patient? We use a templated statement after a consultation with our residents and attending physicians, but because of internal issues, their actual documentation does not appear on the chart until well after the ED encounter. Arewe okay? West Virginia Subscriber Answer: There has to be a linking statement along the lines of those pasted below from CMS Transmittal 811. Additionally, though the ROS and Past/Family/Social History may be gathered by anyone they...

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