tci Medicare Compliance & Reimbursement - 2013 Issue 3

Revenue Booster: Make Your History Documentation Word Perfect

Tip: Avoid repeating yourself. Losing money on your E/M visits? History documentation could be to blame. Use these five tips to help your physician actually document the questions the patient was asked — about what she was experiencing and past medical, family and social history. 1. Remember the difference between the history and the exam. Especially when it comes to the review of systems (ROS) portion of the history, doctors may try to write down things that should actually be counted toward the exam and not the history. Teach your physicians that ROS typically comes from discussing the issue...

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