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Documenting E/M On Your Medical Billing

Documenting E/M On Your Medical Billing

Guidelines for Documenting E/M On Your Medical Billing

Evaluation and management services are some of the most common charges medical billing companies charge today. Since evaluation and management claims are so abundant, it is important to methodically document the occurrences. There are several documentation guidelines for E&M that can improve your medical billing accuracy.

The first guideline, and possibly them most important, is insuring your ICD-9 codes and CPT codes correctly match with the documentation in the medical records. This may seem obvious. However, there have been many times when medical billing has been performed incorrectly in this manner.

Medical records are very important in substantiating procedures and tests billed. When performing medical billing, documentation must be included by the physician explaining why certain diagnostic tests were ordered. Without this, medical necessity will not be established.

There are certain things physicians must document in the records for proper medical billing. For every visit, the doctor must record the chief complaint, any history, findings from a physical exam, any previous diagnostic test results, clinical diagnosis, plan of action, date of service, and the name of the physician. All of these elements must be present in order to submit proper medical billing information. It will keep your firm honest and organized.

Many practices are now requiring a newer guideline. They are asking their physicians to document in the record while the clinical visit is taking place. This is to improve the accuracy of patient records and therefore, easier medical billing later on.

It is extremely important to provide proper documentation for your evaluation and management visits. Since these services are so abundant, any errors could cost your practice a lot of money. Be sure to follow these documentation guidelines to ensure proper medical billing within your office or with an outside firm.

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