Part B Insider (Multispecialty) Coding Alert

Despite the carrier's warnings against trying to game the system and obtain a higher E/M level, anybody who works with doctors knows that it's often a challenge to get them to bill for the service they actually provide, says Lee. Often, physicians will take down a patient's past medical and social history, but forget to include it in the documentation.
 
And they'll bill a level three or four for an encounter that could have justified a higher level, because they don't want to incur the government's wrath. Even when they could have helped to increase their level of service simply by adding a note that says, "patient smoker for 15 years," they don't remember to add it, Lee complains.