decisionhealth Newsletters, Part B News - 2013 Issue 6 (June)
Make documentation legible with pre-printed sheets to avoid 99309 denials
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Article Overview
This Find-A-Code article covers documentation practices for subsequent nursing facility care and how pre-printed exam forms may help practices respond to Medicare review concerns. It focuses on chart legibility, completeness of exam documentation, review of systems structure, medical decision-making support, and provider signature authentication. The piece is intended for physicians, non-physician practitioners, coders, and billing staff working with nursing facility E/M services and Medicare compliance.
Why This Topic Matters
Nursing facility E/M claims can be denied when documentation is incomplete, illegible, or not adequately supported. Understanding the compliance issues discussed in this article can help practices improve documentation processes and reduce avoidable Medicare denials.
Article Sections
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Physician payments
Introduces the documentation and review context for subsequent nursing facility care and Medicare payment issues.
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Cover E/M requirements with exam template
Describes the use of a formatted exam sheet to organize documentation for nursing facility visits and support E/M requirements.
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3 tips to prevent denials
Summarizes common documentation-related problem areas addressed in the article and general prevention themes.
What You Will Learn
- How pre-formatted documentation tools can support nursing facility E/M charting
- Which broad documentation elements are emphasized for subsequent visits
- Why legibility and signature authentication matter in Medicare review
- How practices can organize review of systems content for nursing facility notes
- What areas of documentation are commonly associated with denials in this setting
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Billing staff
- Practice managers
- Compliance staff
Codes Discussed
Code Ranges Discussed
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