Avoid E/M Documentation Errors In Your Medical Billing

Avoid E/M Documentation Errors In Your Medical Billing

Some of the most common services a medical billing company charges, in behalf of a physician’s office, are for evaluation and management services. There are common errors and CPT code misuses for these services. Medicare is probably the most common payer today. There are three things a medical billing company must substantiate with documentation before Medicare will pay: medical necessity, CPT code criteria, and services must be rendered and documented in the patient’s records.

First, when performing Evaluation and management medical billing for a practice, you must ensure medical necessity. Many times simple documentation errors can disprove medical necessity. The chief complaint may have been left out, or the service was not documented at all. The handwriting could also be so bad; the payers may not know what the documentation even says.

CPT code criteria must be met in medical billing in order for a claim to be paid. For example, there have been several instances when an Evaluation and management visit was billed, but it was actually just a call to the pharmacy to fill a prescription. If the physician wasn’t even seen, this is an incorrect medical billing practice.

The last Medicare documentation criteria for medical billing is that services rendered must be documented in the patient’s records. One of the most common reasons Medicare claims get denied is because the documentation provided doesn’t specify what issues were discussed when counseling a patient. This means, what the patient is complaining of and what the physician suggests the patient should do, is not written down in the records. This is required in order to select the right CPT code for medical billing.

Since evaluation and management services are extremely common, it is important to keep their documentation errors to a minimum. Medical billing firms can help you do this. They will make sure all necessary documentation is provided with a claim and will advise you when more is needed. Medical billing firms will prevent evaluation and management documentation errors from occurring.

View all Articles by: Melissa Clark, CCS-P