tci Part B Insider - 2013 Issue 25
EMR Issues: See How An EMR Upcoded This Visit by Two Levels
Review this documentation and determine how you’d code it before you read the solution. When you review a particularly thorough E/M note, your first instinct may be to agree with an EMR’s selection of a high-level code for the physician’s extensive work. But if just one element of a particular code isn’t met, you won’t be able to report it—even if the rest of the documentation is pristine. This is true even if an EMR selects a high level for you. Check out the following note that a family practice physician documented and...
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