decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Answer_Book / Documentation_Guidelines_for_EM_Services / NUMBER_OF_DIAGNOSES_OR_MANAGEMENT_OPTIONS1
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Article Overview
This premium article covers documentation guidance for evaluation and management services, focusing on how clinicians document the number of possible diagnoses and management options considered during an encounter. It is intended for coders, auditors, compliance staff, and clinical documentation reviewers who need to understand the broad documentation expectations tied to encounter complexity.
Why This Topic Matters
Accurate documentation of diagnostic thinking and management activity is a key part of evaluating the complexity of an encounter. This article helps readers understand the general documentation elements that support review of E/M services.
What You Will Learn
- How encounter documentation reflects diagnostic and management complexity
- What types of documentation support an assessment or clinical impression
- How established and undiagnosed problems are generally documented
- How treatment changes and referrals are recorded at a high level
Who Should Read This
- Medical coders
- Clinical documentation integrity specialists
- Compliance auditors
- Physicians and other clinicians
- Practice managers
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