tci Part B Insider - 2013 Issue 2

Part B Revenue Booster: Keep Body Part Descriptions Specific to Avoid Paybacks

Gut vs. stomach vs. GI -- the differences matter. With the OIG continuing to review claims and RAC auditors right on their heels checking your documentation, you can’t afford to maintain sloppy E/M notes. To avoid getting burned over scrutiny of your records, you should ensure that your physicians pinpoint exact locations of patients’ issues so you can count their E/M elements properly. The problem: Many doctors will write "abdomen" instead of "gastrointestinal tract" or even just "GI." The patient’s abdomen isn’t an organ system for purposes of the physical exam portion of the E/M...

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