tci Medicare Compliance & Reimbursement - 2007 Issue 12

DOCUMENTATION: Don't Fall Into 'Double Dipping' Unless You're Sure You Can Justify It

How one statement could rescue your E/M coding levels.Question: Can you use the same element for both history and review of systems (ROS) if the doctor notes it twice?Answer: As long as the physician documents the item clearly you can count it in both areas. A top Centers for Medicare & Medicaid Services (CMS) official, Executive Medical Officer Barton McCann, said so in a famous 1998 letter to Mason Smith with Lynx Medical Systems in Bellevue, WA. "It is not necessary to mention an item of history twice in order to meet the Documentation Guidelines requirement for...

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