tci Medicare Compliance & Reimbursement - 2019 Issue 4

Reader Question: Avoid Cloned Notes’ Scenarios With Expanded Documentation

Question: Our practice lists the chief complaint for all follow-up visits using just “f/u” — we have never had an issue collecting payment, but our coder is concerned that this isn’t compliant. Can you advise? SuperCoder Subscriber Answer: The chief complaint is not thorough enough, and if the physician writes the same thing on every record, he could even be at risk of accusations of “cloned notes.” First and foremost, avoid “follow-up” as a catch-all complaint. All E/M documentation must include a chief complaint, but what the providers list as the chief complaint may...

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