Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you?   Editor’s Note: This is the final installment in a four-part series that examines physician documentation issues as seen by an auditor. In the last installment of this four-part series, I want to discuss the…
Why the Highmark decision—since rescinded—was wrong about medical decision-making relative to medical necessity. When payers and coders downcode evaluation and management (E&M) notes based on medical necessity, how do they determine what level of history and exam is medically necessary for a particular presenting problem? The answer: subjectively.  What is…