BC Advantage - 2020 Issue 10
Focus Providers on Clinically Relevant History and Exam, and Concise Medical Decision Making
Subscribe or sign in to view the full article.
Article Overview
This article explains the documentation considerations tied to the 2021 E/M guideline changes and why they remain important for compliant billing and audit readiness. It is aimed at providers, auditors, and coding professionals who need a practical understanding of how the updated framework affects note quality, medical necessity, and review of service-supporting documentation.
Why This Topic Matters
Understanding these documentation shifts helps practices prepare clinicians for audits, support medical necessity, and reduce risk associated with incomplete or stale notes.
Article Sections
-
2021 E/M documentation changes
Introduces the broader documentation changes and the shift in emphasis from legacy element counting to clinically meaningful note content.
-
Freshly documented history and exam for clinically relevant areas
Discusses the need for documentation to remain current and relevant to the patient encounter, with attention to clinically pertinent findings.
-
Don't become over-reliant on time
Addresses time-based documentation considerations and the importance of aligning recorded time with the services provided.
-
Show your work
Covers the importance of capturing supporting work that informs patient care, including review, discussion, and related service activities.
What You Will Learn
- How the 2021 E/M documentation changes alter the emphasis of provider notes
- Why clinically relevant history and exam documentation remains important
- What general documentation considerations apply when time is used to support a visit
- Why supporting work and review activities matter in medical decision making documentation
Who Should Read This
- Physicians
- Advanced practice providers
- Medical coders
- Medical billers
- Auditors
- Compliance staff
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com