tci Medicare Compliance & Reimbursement - 2019 Issue Q3

Compliance: Master Addenda Requests With This Advice

Tip: Explain why changes are necessary to the documentation. When a coder receives a chart, there’s often a code circled at the top — but it’s the coder’s job to determine whether the documentation matches the code selection. And when it doesn’t, the question arises about whether more can be added when necessary. Consider this coding conundrum: A reader asked this question: “When we see that documentation doesn’t match a code choice, we usually go back to the physician with questions, and sometimes they’ll acquiesce and agree that a lower-level code should...

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