tci Part B Insider - 2014 Issue 44

Part B Documentation: Unclear Organ Site Documentation Could Force Your Claim to Be Downcoded

Physicians should strive to be more precise in E/M documentation. The OIG and Part B MACs are coming up with new and clever ways to poke holes in your evaluation and management documentation, and Medicare is sending different types of auditors to look at your claims. These factors all indicate that you have to be more careful than ever about keeping thorough documentation for your E/M visits. As the MACs continue to create their own audit tools for E/M visits, you should be making sure your records are as airtight as possible, say experts. And one way you could...

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