tci Medicare Compliance & Reimbursement - 2015 Issue 4

Part B Documentation: Keep Your Records as Airtight as Possible

Are you at risk for making this type of error? Vague descriptions can poke holes in your E/M claims. The HHS Office of the Inspector General (OIG), Part B MACs and the Centers for Medicare & Medicaid Services (CMS) are cracking down on shoddy documentation for your E/M visits. As the MACs continue to create their own audit tools for E/M visits, now’s the time to make sure your records are airtight. Watch out: You could be leaving yourself open for downcoding by including imprecise descriptions of body parts in your doctor’s physical exam documentation. The problem:...

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