Category: Misc
Keywords: Reimburshment, Coding (PubMed Search)
Posted: 10/7/2009 by Michael Bond, MD
(Emailed: 10/11/2009)
(Updated: 8/14/2024)
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Reimburshment Pearls:
Often charts are down coded as it is not clear from the documentation that your medical decision making was complex.
For instance, if your final diagnosis is GERD, and you do not document that you were also concerned about angina or a pneumothorax your level 5 chart could be coded as a level 3, since the final diganosis does not seem that complex. In order to prevent this document:
I realize that when you are busy this might be the last thing on your mind, but the difference between a level III chart and a level V chart is about $100, and the only additional work is the 3 minutes it would take to document what you did for the patient.
More to come...
Adapted from Michael A. Granovsky's ACEP lecture entitled :"RVU Killers: The Most Common Reimburshment Documentation Errors"