tci ED Coding & Reimbursement Alert - 2019 Issue Q3

E/M Coding: Return to Sender? How to Know When to Ask Providers for Addenda

Determine when – and how – you should ask the physician to expand documentation. When a coder receives a chart, there’s often a code circled at the top – but it’s the coder’s job to determine whether the documentation matches the code selection. And when it doesn’t, the question arises about whether more can be added when necessary. A coder submitted a question to ED Coding Alert asking about that very situation. “When we see that documentation doesn’t match a code choice, we usually go back to the physician with questions, and sometimes...

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