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Emergency Department Coding & Reimbursement Alert

Reader Question:
How Do You Support Caveat Intent?

Question: How does CMS audit records when the acuity caveat is used to explain the ED physician’s inability to obtain information? Specifically, does the physician have to write a note that states, “Unable to obtain info due to ... no other source available”? Or does the auditor consider the entire medical record (the nurse’s notes, EMS notes, etc.)? Supercoder Subscriber [...]