Outpatient Facility Coding Alert - 2014 Issue 9
Physician Notes: Unable to Get Patient History? Follow These Tips
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Article Overview
This article covers Medicare documentation expectations when a physician cannot obtain parts of a patient history, along with a CMS policy update about denying related claims under medical review. It is aimed at physicians, coders, billers, and compliance staff who handle E/M documentation and Medicare denial risk.
Why This Topic Matters
The topic matters because incomplete history documentation can affect E/M support, and CMS’s related-claims policy can broaden the financial impact of a denial beyond the original claim.
Article Sections
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Unable to obtain patient history for E/M documentation
Discusses the circumstances in which a patient history cannot be fully collected and the broad documentation topics involved. It also addresses how the issue is framed in a Medicare E/M context.
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CMS guidance on related claims
Summarizes a CMS update about claims that may be treated as related during medical review and the potential denial implications. The section highlights the operational impact for claims processing and compliance.
What You Will Learn
- How the article frames incomplete patient history in the context of E/M documentation
- What broad documentation elements are discussed when history cannot be fully obtained
- What the article says about a CMS update involving related claims under medical review
- Why the policy update may affect denial management and reimbursement risk
Who Should Read This
- Physicians
- Medical coders
- Billing staff
- Compliance teams
- Practice managers
Modifiers Discussed
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