Kicking off the CodeCast in September, Terry discusses auditing and the objectives of looking for documentation support of the E/M record.
Terry focuses on not losing sight of “medical necessity” within the record and making sure the physician (or provider) can justify not only the level of E/M service but also the ordering of tests on a specific DOS.
She also advises on how to respond to a physician when they believe that only the physician should make clinical judgments on the documented record, even in an audit.
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