Coding, Chart Documentation and Reimbursement - Thurston ...

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Service Type Billed to Part B (BETOS codes) Coding, Chart Documentation and Reimbursement Medicare CERT Errors Insufficient Documentation Type of Error Medically Unnecessary Services Incorrect Coding Other Hospital visit - initial 38.3% 0.0% 60.8% 0.2% Office visits – new 30.5% 2.1% 64.5% 2.3% Nursing home visit 51.6% 0.4% 44.1% 0.2% Hospital visit – subsequent 62.8% 0.0% 35.8% 0.0% Lab tests - other (non- Medicare fee schedule) 66.4% 31.8% 0.3% 0.3% Chemotherapy 95.1% 4.6% 0.3% 0.0% Minor procedures - other (Medicare fee schedule) 82.8% 12.4% 2.0% 1.1% Office visits – established 54.4% 0.5% 42.8% 0.8% Lab tests - other (Medicare fee schedule) 62.5% 25.5% 11.9% 0.0% 12
Coding, Chart Documentation and Reimbursement Common E/M Service Documentation Errors -History • Indicate clearly the chief complaint and/or reason for the visit. Do not limit the chief complaint to “follow-up” without identifying the problem(s) being followed. • Describe the history of the present illness fully and in such a way that the nature of the presenting problem is clear. 13
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Coding, Chart Documentation and Reimbursement - Thurston ...

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