BC Advantage - 2015 Issue 7
Tip: Understanding Your Risk
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Article Overview
This compliance-focused tip discusses documentation roles in evaluation and management services, with attention to history-taking components, electronic medical record workflows, and audit risk. It is aimed at physicians, non-physician practitioners, ancillary staff, and coding/compliance professionals who need a broad understanding of how history documentation responsibilities are divided and why improper delegation can create billing risk.
Why This Topic Matters
Accurate history documentation is central to evaluation and management reporting and audit defensibility. Understanding the boundaries between provider documentation and ancillary staff activity helps organizations reduce compliance risk and avoid claim denials, overpayment exposure, or other audit findings.
What You Will Learn
- How history documentation responsibilities are framed in evaluation and management services
- Which parts of the patient history are discussed as being within ancillary staff involvement
- Why electronic medical record workflows can create compliance risk
- How documentation errors may affect audit outcomes and billing integrity
- General approaches to reducing risk in history documentation processes
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Compliance officers
- Practice managers
- Ancillary clinical staff
- Auditors
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