tci Part B Insider - 2014 Issue 22

Part B Mythbuster: Op Note Scrutiny Focuses on More Than Just the Title

Plus: Bust this myth about same-day E/M services. Myth: You should work twice as hard on the title of your physician’s medical record than you should on the note itself, because the title 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 didn’t perform the procedures. For instance: Suppose the subject of the physician’s note is “Alan Johnson’s corticosteroid injection,” but then he only dictates details about the diagnosis and E/M service...

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