Compliance: Beat Auditors to the Punch: Use Self-Audits to Correct Your Documentation Glitches

Why This Topic Matters

Accurate E/M documentation affects claim support, compliance, and reimbursement integrity. Understanding common documentation weaknesses can help practices improve internal review processes and prepare for audit scrutiny.

Article Sections

1. Background

   Introduces the role of self-audits in finding documentation and billing issues before external review. Frames the article around compliance improvement and reimbursement accuracy.

2. Get Into the Habit of Documenting Time Spent

   Addresses documentation of time in E/M encounters and how practices can improve their internal documentation habits. The section presents guidance through a question-and-answer format.

3. You Must Meet Minimum History Requirement to Bill New Patient

   Reviews documentation expectations for new patient E/M services, with emphasis on required history components. The section discusses how missing elements can affect claim support.

4. Doctor Overdocuments History, Exam? You Can't Always Bill 99215

   Examines the relationship between extensive documentation and visit level selection. It discusses how medical necessity and encounter complexity factor into E/M coding decisions.