Coding, Chart Documentation and Reimbursement - Thurston ...

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Documentation Improvement for Physician Practices Common E/M Service Documentation Errors – Medical Decision Making • MDM must address the chief complaint. Additional conditions or concerns can be address and may be more relevant but it is important not to ignore the original reason for the encounter. • Free-floating diagnosis: Assessment: Hypercholesterolemia, stable. Not on problem list, not elsewhere in chart, no labs referenced in note, no cholesterol medicine. 20
Coding, Chart Documentation and Reimbursement • Common E/M Service Documentation Errors – Counseling & Coordination of Care (Time) • The documentation does not support the requirement that at least 50% of the visit was devoted to counseling and/or coordination of care. Clinician notes she spent “around 20 minutes,” or “approximately 35” minutes with the patient. 21
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