Wiki EHR, Prompting Doctors documentation on exams

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CRSTRADTMAN

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Can anyone tell me where there might be referrence to avoiding prompting doctors on what to document on to get a higher level of charge. We were asked if we could give the doctors clues on what would increase their CPT level at the time of the visit. I thought I read somewhere that you should not prompt the doctor while documenting :confused:
 
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Medicare has guidance on this...

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."

Page 38

https://www.cms.gov/manuals/downloads/clm104c12.pdf
 
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