tci Medicare Compliance & Reimbursement - 2007 Issue 14

CODING & COMPLIANCE: Look For Questions That Go Beyond The Patient's 'Chief Complaint'

Don't turn your E/M claims into audit bait.When you assign an evaluation & management (E/M) level to your doctor's visit, don't get hung up on trying to make statements go as far as possible. Rather, you should pay attention to how in-depth the doctor went with questions, say experts.You can credit the same statement for both the history of present illness (HPI) and the review of systems (ROS) in some cases, officials from the Centers for Medicare & Medicaid Services (CMS) and some carriers have said. But that doesn't mean you can stretch one statement to bump...

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