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Evaluation & Management Tips

As we move closer to Healthcare reform implementation, auditors will become increasingly tougher on documentation requirements. Medical necessity is defined by the American Medical Association as “Healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site and duration; and (c) not primarily for the convenience of the patient, physician, or other healthcare provider.” Evaluation and management documentation must demonstrate medical necessity for the visit and thus must include specific requirements to avoid rejection.
First, the chief complaint should be listed in the first or second sentence. It might even be helpful to spell out the words “chief complaint” and then the list the reason for the visit. Make it as easy and foolproof as possible if an auditor or payer should review the notes. Every note must stand on its own. In other words, even if a patient is a repeat patient and you’ve listed out their chronic problems in other notes, it’s important to list out the chief complaint during every visit, every time. If the note isn’t documented properly, payment can be denied or rescinded.
Secondly, the chief complaint should not be ambiguous. Be specific. If the patient is coming in for a variety of complaints, make sure the chief complaint is listed as such.
A physical exam should be conducted even though Medicare doesn’t explicitly require it. Some carriers require it so unless you know that yours does not, you should document the physical exam. Coding guidelines require a physical exam of varying degrees depending on the chosen code.
Medicare generally expects to see evaluation and management services billed every three months for patients with chronic, stable conditions. However, medical necessity should always dictate how often a patient is seen. Documentation should always demonstrate the medical necessity for the visit so be sure your notes indicate the need. If your claim is denied for payment or an overpayment is requested based on a RAC audit, appeal with your records. Practices have been successful in overturning the rejection when their documentation supported the visit.
In summary, stricter standards are going to become the new norm as reimbursement levels decline and payers try to hold on to payments. It’s up to providers to keep this from happening by ensuring their documentation passes muster to support medical necessity. Self-auditing should be implemented to look for deficiencies before an auditor finds them.

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