Proper documentation of your Evaluation and Management (E/M) Services is crucial when submitting claims to Medicare for your practice.
A short fact sheet was produced in April 2011 by the "Department of Health And Human Services - CMS" on proper E/M documentation. Topics addressed on this fact sheet include:
- Components of an Evaluation and Management (E/M) Service
- Tips on Documentation: ‘If It Wasn't Documented, It Wasn’t Done!’
- Determining the Correct Level of Code
- Links to Resources for: "1995 Documentation Guidelines for Evaluation and Management Services” and “1997 Documentation Guidelines for Evaluation and Management Services"
To download and view the full E/M documentation fact sheet published by the Department of Health And Human Services - Centers for Medicare & Medicaid Services, please go to the following link: Evaluation and Management (E/M) Services: Complying with Documentation Requirements
Are you following the necessary steps to document your codes correctly?
- To ensure that you are coding and charging correctly, your documentation must be accurate.
- The coder must evaluate all of the physician's dictation and base their codes on that.
- If yourself or your physician does not document correctly, you may not be receiving appropriate reimbursement.
The following link will direct you to download and view a guideline where you can evaluate if you are following the necessary steps in order to document your codes correctly: ED E/M Documentation
