tci Medicare Compliance & Reimbursement - 2013 Issue 5

Coding Strategies: Take These Steps to Ensure Your Time Documentation Makes the Grade

Auditors will not be impressed if you rely on the physician’s memory; only sound documentation will hold up in court. You know that you deserve to be paid for 99215, but you can expect it to get downcoded unless you have the documentation to prove that you really spent an hour with the patient. Apart from being cautious about recording the necessary elements, be certain to record time spent in counselling the patient and/or family. Background: When medical auditors review E/M claims, they typically code the reports based on history, exam, and medical decision-making, unless the physician meets...

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