tci Medicare Compliance & Reimbursement - 2014 Issue 6
Industry Notes: Unable to Get Patient History? Follow These Tips
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Article Overview
This article is aimed at clinicians, coders, billing staff, and compliance professionals who document evaluation and management services or handle Medicare claims review. It explains general documentation expectations when patient history cannot be obtained and summarizes a CMS directive about related claims that may be denied in connection with a reviewed claim. The discussion is relevant to anyone tracking Medicare contractor audit practices and documentation support requirements.
Why This Topic Matters
The article highlights documentation gaps that can affect E/M support and describes a Medicare claims-review policy change that may broaden denial impact across connected claims. It is important for practices that want to reduce audit risk and understand how related documentation can affect reimbursement.
What You Will Learn
- How the article frames documentation challenges when a patient cannot provide a full history
- What kinds of circumstances may be cited in documenting missing history information
- How CMS describes related claims in the context of medical review denials
- Which Medicare contractor review entities are referenced in the policy update
- Why connected claims may be affected when documentation overlaps
Who Should Read This
- Physicians
- Coders
- Billing staff
- Compliance professionals
- Practice managers
- Medicare-participating providers
Modifiers Discussed
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