tci Medicare Compliance & Reimbursement - 2007 Issue 12
DOCUMENTATION: Don't Fall Into 'Double Dipping' Unless You're Sure You Can Justify It
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Article Overview
This article explains a documentation issue in evaluation and management coding that affects how clinicians and coders interpret history and review of systems entries. It discusses CMS guidance, carrier-level caution, and the general documentation practices that matter when determining service levels and medical necessity. The piece is intended for coders, auditors, compliance staff, and clinicians who work with E/M documentation.
Why This Topic Matters
Accurate E/M documentation supports defensible level-of-service reporting and helps reduce audit risk when record elements appear in more than one part of a note.
What You Will Learn
- How E/M documentation guidance addresses overlapping history and review of systems information.
- Why documentation clarity and defensibility matter in record review.
- What general cautions apply when relying on the same statement in multiple documentation areas.
- Why clinicians and coders should consider the broader context of the note rather than only its headings.
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians
- Billing staff
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