BC Advantage - 2012 Issue 9
Something to Talk About
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Article Overview
This article discusses outpatient and clinic documentation practices that influence evaluation and management coding, especially when physicians perform work outside the patient’s presence. It explains why certain categories of medical decision making may be underdocumented in electronic medical records and how clearer documentation can affect level-of-service selection. The piece is aimed at coders, compliance staff, and clinicians involved in documentation improvement, with examples drawn from specialty practice and EMR workflows.
Why This Topic Matters
Accurate documentation can better reflect the work actually performed during a visit and may change the reported evaluation and management level. The article is relevant for reducing underdocumentation, improving coding accuracy, and supporting compliance-focused provider education.
What You Will Learn
- How outpatient and clinic documentation affects evaluation and management level selection
- Which broad types of work are commonly performed outside the patient’s presence
- Why certain medical decision making elements may go undocumented in electronic records
- How clearer documentation can support more complete capture of physician work
- How documentation improvement discussions may be framed with providers
Who Should Read This
- Medical coders
- Compliance specialists
- Physician documentation educators
- Billing staff
- Clinicians documenting outpatient visits
Codes Discussed
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