July 2013

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   “When there is more documentation found in the note or the note looks more complete, oftentimes we can think and/or feel that we are justified in billing a higher level of service so this can lead to the danger of billing a higher level evaluation and management (E/M) code,” says Dr. Aung, a Certified Professional Medical Auditor, a Certified Surgical Foot and Ankle Coder and member of the American Association of Professional Coders. “What we all should keep in the forefront is that the documentation should support what we did for the patient on the particular encounter. It should stand alone to give us a picture of the particular event, answering all of the questions of who, what, where, when, how and why.”

   In Dr. Aung’s opinion, the most effective techniques to ensure accurate billing are to be knowledgeable of coding guidelines and documenting accurately to reflect the specific encounter. She suggests that vendors turn off the E/M “wizard” along with the ability to clone information and/or pushing forward information from one note to the next.

   Furthermore, Dr. Aung says a well-designed template can help a clinician be more thorough and document more accurately, which reflects the encounter and treatment as well as the decision making process. However, she warns that templates with pre-filled information can be dangerous as the note may appear the same from one visit to the next and/or does not support medical necessity for that particular encounter.

   “These are the ‘canned’ notes that will not stand up to an audit,” she explains.

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