tci Medicare Compliance & Reimbursement - 2010 Issue 23

Part B Mythbuster: How to Make Your E/M Documentation Bullet-Proof Even With Few Symptoms

You may still be able to bill a level-four E/M visit for a patient with abnormal test results. Myth: You can't bill an evaluation and management claim unless the patient has pain or some similar complaint.Reality: Sometimes it's test results that prompt a patient visit, not pain or even a complaint. A patient may come to a specialist or emergency physician because he or she has abnormal test results.Challenge: It can be a challenge to obtain four out of eight elements of the history of present illness (HPI) when the patient comes in with severe anemia, for...

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