tci Medicare Compliance & Reimbursement - 2013 Issue 3

Revenue Booster: Body System or Site? Be Sure You Clarify

Escape scrutiny — and ensure proper payment — with specific body part descriptions. If you want to avoid coming under the microscope during audits and OIG reviews, then you must clean up your doctor’s E/M documentation act. To get the credit for the exam the physician performed, it is vital that the E/M notes are clear cut and mention organ systems rather than generalized body parts. The problem: Many doctors will write "abdomen" instead of "gastrointestinal tract" or even just "GI." The patient’s abdomen isn’t an organ system for purposes of the physical exam portion...

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