tci Part B Insider - 2015 Issue 1

On-the-Go Documentation Tips

You’ve read about what makes a good and bad Ob report, but here’s what you can do to make sure you’re reading the documentation correctly every time: Read the note all the way though to see if the title of the procedure matches the note. Always code from the note, not the title. Highlight the procedures the physician performed. If you have trouble understanding anything, ask the physician to explain. Assign codes. Check for any modifiers that might be appropriate and check the CCI edits for bundled codes. Have a colleague check your codes for accuracy...

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