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Evaluation & Management Services Guidelines
Nancy-Ann DeParle, Administrator
Health Care Financing Administration
JAMA. 2000;283:3061.
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| Since this article does not have an abstract, we have provided the first 150 words of the full text and any section headings. |
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This week we are unveiling new, draft documentation guidelines for evaluation and management (E&M) services. After pilot testing, these simplified guidelines will replace the current ones.
These guidelines are important because a properly documented medical record is essential to good clinical care. It eases communication and coordination among physicians and other health care professionals. Proper documentation also ensures that taxpayer dollars are spent in accordance with the law and that the level of service in a submitted claim was, in fact, the level provided.
Unfortunately, too much care is not being properly documented. The congressionally mandated audit of fiscal year 1999 Medicare claims by the Department of Health and Human Services Inspector General (IG) attributed $5.5 billion in improper payments to inadequate or nonexistent documentation.
For example, one physician billed for nine hospital visits but documented only three. Another physician billed for a level III office visit . . . [Full Text of this Article]
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