Coding and Documentation

In need of coding help?

AAPC's Coding Edge Magazine published an article on  documentation and offered the following tips:

• Reports Don't Need to Be Lengthy to Be Complete
• Minimum requirements that need to be in the medical record are the following:
• 1. History of present illness (HPI)
• 2. Examination
• 3. Medical Decision Making (MDM) components
• If you are documenting radiology, you must document the technique as well as the findings of the study
• Documentation Must Be Relevant
• Extraneous documentation can do more harm than good
• Stick to what's relevant and be thorough
• Documentation Must Support Specific Coding
• Select the code that accurately identifies the service or procedure performed
• Documentation my support the code you select
• Document Same-Day Procedure, E/M with Special Care
• Procedures provided on the same day as an E/M service may cause red flags
• When you report an additional study your documentation must pass the "highlighter test" - supports the initial service

• * Important to remember the "golden rule" - "If it isn't documented, it wasn't done"*

To download the full article, please click here: Let Documentation Drive Your Coding

For additional billing and coding resources, please click the following link: Medical Reimbursement Billing and Coding Resources

Guidelines for Teaching Physicians, Interns, and Residents

Do you feel your residents are losing you money in documentation?

The Centers for Medicare and Medicaid Services (CMS) produced a short fact sheet with Guidelines for Teaching Physicians, Interns and Residents in December 2011.

Highlights of the Fact Sheet Include:

• Payment for Physician Services in Teaching Settings
• Services Furnished by an Intern or Resident Within the Scope of an Approved Training Program
• Services Furnished by an Intern or Resident Outside the Scope of an Approved Training Program (Moonlighting)
• Billing Requirements for Teaching Physicians
• General Documentation Guidelines
• Evaluation and Management Documentation Guidelines
• Evaluation and Management Documentation Provided by Students
• Exception for Evaluation and Management Services Furnished in Certain Primary Care Centers
• Glossary Highlighing Key Terms
• Resources Page with additional links to external websites with advice for Teaching Physicians, Interns, and Residents

To download and view the full fact sheet, please go to the following link:  Guidelines for Teaching Physicians, Interns and Residents