tci E/M Coding Alert - 2013 Issue 9

History How-To: Point Your Provider in the Right Direction With These 5 History Tips

Beware of counting elements in more than one place. The task seems simple: The practitioner has to obtain all of the details of where the patient’s illness came from and what the patient is experiencing. This may be simple from a coding standpoint, but if your physician doesn’t document the necessary elements for you to compile a useful history, your claim could be downcoded, or even uncodeable. Luckily, you can show your physicians how to obtain the perfect history, with the following five tips. 1. Remember the difference between the history and the exam. Especially when it...

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