Complexity of medical decision-making is key, but you can’t bill for something you didn’t do.This article was prompted by a Talk Ten Tuesdays listener’s question regarding his personal experience with the healthcare profession. He was evaluated in an emergency department (ED), never examined, but discovered a complete physical examination in…
EDITOR’S NOTE: The following is the second installment in a three-part series on outpatient clinical documentation integrity.In Part 1 of this series, we detailed the concept of risk adjustment and how historically, the healthcare industry rewarded volume under the fee-for-service (FFS) model. The Centers for Medicare & Medicaid Services (CMS)…