tci Part B Insider - 2004 Issue 31

Most Physicians Omit Information That Could Increase Pay

Despite the carrier's warnings against trying to game the system and obtain a higher E/M level, anybody who works with doctors knows that it's often a challenge to get them to bill for the service they actually provide, says Lee. Often, physicians will take down a patient's past medical and social history, but forget to include it in the documentation.  And they'll bill a level three or four for an encounter that could have justified a higher level, because they don't want to incur the government's wrath. Even when they could have helped to increase their level of...

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