tci E/M Coding Alert - 2023 Issue Q1

Documentation: Bolster Patient Records With Accurate Documentation

Hint: Medical record notes should include both reason for encounter and plan of care. Comprehensive documentation is key to establishing and maintaining accurate medical records for patients, as well as ensuring timely and accurate payment for providers. Payers and auditors look to providers’ notes for the details to support medical necessity, accurate and appropriate evaluation and management (E/M) service levels, and other aspects of care. If your provider’s documentation doesn’t have enough information for you to do your job as a coder, it’s your responsibility to query them. Use these helpful guidelines for reviewing patient records...

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