tci Part B Insider - 2015 Issue 40

E/M Coding: Make Your Documentation Problems Ancient History

3 payers share tips on what you should do if you can’t obtain a history from a patient. Examining a patient is typically straightforward for most practitioners—but getting the history can be a little trickier, particularly if the patient can’t speak and no family is present to fill in the blanks. But failure to obtain a history doesn’t mean your claims are doomed. In fact, most payers have specific rules on how to react in this situation. The Insider recently scanned hundreds of pages of payer policies, with the following being most applicable to this...

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