tci Medicare Compliance & Reimbursement - 2012 Issue 3

Part B Revenue Booster: Document Counseling and Coexisting Conditions to Justify E/M Level

Show physicians how to thoroughly document all diagnoses addressed to ensure complete documentation. If your physician sees a large number of patients who have complex cases with multiple diagnoses, selecting an appropriate E/M level might be a challenge. However, once you take the coexisting conditions and the amount of time spent counseling the patient into account, you should be able to see the whole picture -- and you may justify selecting a higher E/M level than you thought. The key? Show your physicians how to thoroughly document every condition they evaluate, and not just the presenting complaint. Checking for...

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