tci Part B Insider - 2011 Issue 3

Clip And Save: Use This Simple Tool to Ensure You Cover Every System Possible

Confirming that your doctor's documentation captures every system he reviewed guarantees you pick the correct E/M level.One easy way to ensure that your physicians document the E/M visit components is to create a template he can follow. As mentioned in our article, "99214: Tally Review of Systems Accurately And You May Qualify for Higher-Level Codes," some physicians forget to document negative systems -- a simple form like this can help confirm that your doctor captures each and every system he reviews during an encounter. You can use this sample or tailor it to fit your practice's needs...

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