Primary Care Coding Alert

Heads up: Dig past 'follow-up' for acceptable chief complaint. E/M coding might be part of your everyday routine, but that doesn't mean you have to fall into a coding rut. An education expert with Palmetto GBA, a Part B MAC in seven states, offers five simple ways to keep your claims clean and sailing through the reimbursement process. Change the Documentation Wording Although you might think of "cloned documentation" as only existing when using electronic health records (EHRs), the truth is that even paper records can be considered "cloned," if they are all worded exactly alike. The answer? Help providers remember to document things differently, so they don't look like carbon copies. "Whether the cloned documentation is handwritten, the result of a pre-printed template, or use electronic health records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services," says Carrie Weiss, senior provider [...]