Medicare Compliance & Reimbursement - 2005 Issue 36
EVALUATION AND MANAGEMENT: Don't Get Burned By Trailblazer's New E/M
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Article Overview
This article discusses new audit guidance from TrailBlazer Health Enterprises affecting evaluation and management documentation. It focuses on how the guidance differs from long-standing E/M documentation standards, and it outlines the general categories of documentation and clinical activity that may affect medical decision-making scoring. The piece is relevant to physicians, coders, auditors, and compliance staff who need to understand how evolving carrier audit practices may affect chart review.
Why This Topic Matters
Understanding this guidance may help providers and coding staff prepare for audits and document E/M services in a way that aligns with carrier-specific review expectations. The article is important because it highlights a possible shift in how documentation is evaluated and how medical decision-making may be scored.
What You Will Learn
- How a carrier-specific audit approach may affect evaluation and management documentation review
- What broad types of documentation activity may be considered in medical decision-making scoring
- How documentation practices may differ from general E/M guideline expectations
- What stakeholders should review to assess audit readiness
Who Should Read This
- Physicians
- Medical coders
- Medical auditors
- Compliance staff
- Billing staff
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