News: Thorough documentation required for E/M billing, CMS reminds providers

CDI Strategies - Volume 10, Issue 42

Physicians often ask why documentation matters to them. Last week, CMS sent out a reminder regarding the importance of complete and accurate documentation related to physician evaluation and management (E/M) codes.

In a 2012 study report, the Office of the Inspector General (OIG) noted that a number of physicians increased their billing of higher level, more complex and expensive E/M codes. Many providers submit claims coded at a higher or lower level than the medical record documentation supports. The following resources can be used to bill correctly for E/M services:

CDI specialists should review the requirements and guidance to prepare themselves when providers come to them and ask for help. 

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