tci Part B Insider - 2009 Issue 20

PART B MYTHBUSTER: Auditors Review the Op Note -- Not Just Its Title

Plus: Bust this myth about same-day E/M services. Myth: The title of your physicians medical record is enough to justify the codes you report. Reality: The physician must document the services he performs in the body of the record or an auditor would assume that he didnt perform the procedures. For instance: Suppose the subject of the physicians note is Patient Smiths Corticosteroid Knee Injection, but then he only dictates details about the diagnosis and E/M service (not an injection) in the body of his report. Solution: You can report the E/M service but not the injection. Explanation: Most...

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