tci General Surgery Coding Alert - 2004 Issue 10

Don't Risk Losing Thousands on Subsequent Hospital Care

Strengthen documentation to improve your E/M claimsAre you worried that your surgeon is downcoding subsequent-care claims, but you don't know what do? Use our experts' answers as a guide for documenting subsequent-care E/M components, body systems, and service levels. The bottom line: Underdocumenting can result in undercoding, which in a year could cost the surgeon thousands of dollars. For example, suppose your surgeon believes his documentation won't support a higher-level subsequent-care code, so he always uses 99231. Because 99231 pays about $20 less than 99232, downcoding these claims just 10 times in a month could cost your...

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