Part B Insider - 2003 Issue 3
Say Goodbye to Underpaid E/M Claims
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Article Overview
This article focuses on emergency department evaluation and management documentation and how incomplete physician documentation can contribute to lower E/M levels and missed reimbursement. It discusses the major components of history documentation, the role of physician-authored notes, and general considerations for review of systems and past/family/social history in the ED. The piece is aimed at coders, compliance staff, and emergency department physicians who want to understand documentation expectations and improve claim accuracy.
Why This Topic Matters
Accurate ED documentation helps support the level of service reported and can reduce underpayment tied to incomplete history elements. The article is relevant for teams looking to align physician charting with E/M requirements and payer expectations.
Article Sections
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HPI: Know What You're Looking For
Explains the history of present illness as a documentation focus for ED E/M coding and reviews the main elements coders look for in physician notes.
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ROS: Help Your Physicians
Covers the review of systems portion of ED documentation and describes its general relationship to payer and Medicare history requirements.
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PFSH: What Does and Doesn't Count
Discusses past, family, and social history documentation in the ED and the broader issue of what may be considered relevant to the current encounter.
What You Will Learn
- How emergency department documentation can influence E/M level selection
- Which broad history components are emphasized in ED chart review
- Why physician documentation matters for supporting ED claims
- How review of systems and past/family/social history are discussed in the context of reimbursement
Who Should Read This
- Emergency department coders
- Health information management professionals
- Compliance staff
- Emergency department physicians
- Billing staff
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