tci Part B Insider - 2007 Issue 9

PART B MYTH BUSTER: One Statement Could Rescue Your E/M Coding Levels

But don't fall into 'double dipping' unless you're sure you can justify itMyth: You can't use the same element for both history and review of systems (ROS) unless the doctor notes it twice. Reality: As long as the physician documents the item clearly you can count it in both areas. A top Centers for Medicare & Medicaid Services (CMS) official, Executive Medical Officer Barton McCann, said so in a famous 1998 letter to Mason Smith with Lynx Medical Systems in Bellevue, WA. -It is not necessary to mention an item of history twice in order to meet the Documentation...

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