Helpful Medical Review Tips
Miscellaneous
- When submitting documentation involving lab work and/or diagnostic tests, be sure to include signed orders, test results and notes documenting the medical necessity of the service.
- Physical Therapy service notes should always include the progress your patient is making at each visit based on the set goals.
- Copies of operative reports sent to you from the hospital that have
NOT been signed, should not be signed in your office and placed in the
patient's chart, this is considered altering the medical record and not
acceptable. Either attached an attestation to the note for your chart
or ask the hospital to forward to you the signed version from their chart.
When submitting operative reports please submit a copy of the original
SIGNED version or an attestation. An
example of an attestation can be found here
. - During a scheduled screening mammogram, the patient tells the tech that they felt a lump in their breast. Based on this information, a diagnostic mammogram is done instead of the screening. Keep in mind that a physician's order is a required component of a diagnostic mammogram.
Evaluation & Management
- It is the accurate documentation of the medically necessary services rendered pertinent to the patient's needs at the time of the encounter that determine the level of E&M code to be selected, not the volume of documentation.
- Initial office E&M codes may be billed if the patient has not been seen by the treating provider for three years and has not been seen by another physician of the same specialty in the group within the past three years.
- Initial office evaluation & management codes may be billed if the patient has not been seen by the treating provider for three years and has not been seen by another physician of the same specialty in the group within the past three years.
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