decisionhealth Newsletters, Answer Books - 2008 Issue 1 (January)
Answer_Book / Evaluation_and_Management_Services / E_M_chart_auditing_QandA
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Article Overview
This article covers practical questions about evaluation and management documentation and chart auditing. It discusses how reviewers look at history elements, record incorporation, legibility, established versus new problems, and selected medical decision-making topics under E/M documentation guidance. It is aimed at coders, auditors, compliance staff, and clinicians who document E/M services.
Why This Topic Matters
E/M documentation is a frequent audit focus, and small differences in how information is recorded can affect whether a service is supported. This article helps readers understand the documentation framework that reviewers and carriers may expect when evaluating records.
What You Will Learn
- How E/M documentation is reviewed in a chart-auditing context
- How history elements may be incorporated into the medical record
- How legibility and signer identification are viewed in documentation review
- How established versus new problems are considered in medical decision-making
- How selected treatment and data-review concepts are discussed for E/M services
Who Should Read This
- Medical coders
- Certified professional auditors
- Compliance staff
- Physicians and other clinicians
- Practice managers
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