decisionhealth Newsletters, Answer Books - 2008 Issue 12 (December)
Answer_Book / Documentation_Guidelines_for_EM_Services / NUMBER_OF_DIAGNOSES_OR_MANAGEMENT_OPTIONS
Subscribe or sign in to view the full article.
Article Overview
This premium article is part of documentation guidance for E/M services. It covers how the number and complexity of diagnoses or management options and the amount and complexity of data reviewed are reflected in the medical record, including documentation of assessments, treatment changes, referrals, diagnostic testing, and review of outside information. It is intended for coding and compliance professionals, clinicians, and auditors who need to understand the documentation expectations associated with medical decision making.
Why This Topic Matters
Understanding these documentation expectations helps users assess whether an encounter record supports the level of service reported and whether the record shows the clinical work considered during the visit.
Article Sections
-
Number of Diagnoses or Management Options
This section discusses how the scope of problems addressed and the complexity of management decisions are considered in E/M documentation. It also addresses the need to document assessments, impressions, referrals, and treatment-related changes.
-
Amount and/or Complexity of Data to Be Reviewed
This section covers documentation related to diagnostic data review and the use of additional sources of information. It includes review of tests, old records, outside history, and discussion or interpretation of study results.
What You Will Learn
- How encounter documentation reflects the number and complexity of problems addressed
- What types of documentation support assessment and management activity
- How data review contributes to E/M documentation complexity
- What kinds of outside information and test review should be recorded
- Which record elements are relevant to referrals, consultations, and follow-up evaluation
Who Should Read This
- Medical coders
- Compliance staff
- Auditors
- Physicians and other qualified health care professionals
- Practice managers
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com