Despite the confusion over the implementation of the 1997 Evaluation and
Management (E/M) Guidelines, EDs must still adhere to either the 1995
or 1997 version. The 1995 guidelines are considered most beneficial to
emergency medicine. Here are some key tips to ensure ED physicians are
providing the right documentation to justify the appropriate level of
service.
Remind ED physicians to document vital signs, orders, ED course, critical care time in dictations. (Coders dont always get the nurses notes.) For templated records, review for consistency and accuracy in how templates are used. Routinely communicate problems to physicians until resolved. Provide copies of records that indicate inconsistency between stated problems or RN/MD notes.
Encourage physicians to discontinue use of term non-contributory, when documenting the history. Recommend, reviewed and negative. Ask them to indicate whether nurses notes have been reviewed, and include references to pertinent information.
Remind the MDs to always record their review of system(s) identified in the history of present illness, plus other related systems. Remind them also that they must have a review of systems for all E/M levels but the lowest (99281).
If patient information is unobtainable or unreliable, the physician must record the reason for this in order to satisfy stated requirements.
Remind ED physicians to document vital signs, orders, ED course, critical care time in dictations. (Coders dont always get the nurses notes.) For templated records, review for consistency and accuracy in how templates are used. Routinely communicate problems to physicians until resolved. Provide copies of records that indicate inconsistency between stated problems or RN/MD notes.
Encourage physicians to discontinue use of term non-contributory, when documenting the history. Recommend, reviewed and negative. Ask them to indicate whether nurses notes have been reviewed, and include references to pertinent information.
Remind the MDs to always record their review of system(s) identified in the history of present illness, plus other related systems. Remind them also that they must have a review of systems for all E/M levels but the lowest (99281).
If patient information is unobtainable or unreliable, the physician must record the reason for this in order to satisfy stated requirements.
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