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Did you know that under-documenting poses an audit hazard for any specialty provider? This is not spoken about too loudly by payors since their primary focus is identifying overpayments, rather than underpayments. Nevertheless, I believe a proactive approach to documentation and coding compliance through education would better serve the nation’s healthcare practitioners and their patients.
This week’s documentation and compliance tip focuses on documenting orthopedic specialties in the medical record based on overarching medical decision-making (MDM) from the 2021 Evaluation and Management (E/M) Guidelines for Office and Other Outpatient Settings. Meaningful revisions are also found in 2023 and 2024. This tip is specific to the data analyzed column in the MDM Table. My experience has found that numerous records are in fact under-documented, and therefore, underpayments could be made. In other words, orthopedic practices are at risk of not being reimbursed appropriately upon first claims submission.
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