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Otolaryngology Coding Alert

Make Good ROS Documents Routine to Avoid Charges of Overcoding E/Ms

Published on Mon Jan 12, 2009

Don't undercode the level-4 and -5 services your ENT performs. You already know that insurers scrutinize your practice's evaluation and management levels to see whether you-re coding more high-level E/Ms than the average ENT. Don't undercode out of fear of the auditor -- instead, get in the habit of good documentation to back up your practice's good patient service. Evaluation and management of otolaryngology patients can be complicated business. A thorough review of systems is an everyday thing for an ENT, so make sure good documentation of ROS is routine, too. Level-four and -five E/Ms are not that uncommon for an ENT's practice, so mastery of your doctor's review of systems is critical to backing up codes like 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity [...]
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