decisionhealth Newsletters, Answer Books - 2009 Issue 10 (October)
Answer_Book / Evaluation_and_Management_Services / Watch out for buzzwords in EM documentation
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Article Overview
This short Find-A-Code article discusses documentation clarity in evaluation and management (E/M) services. It focuses on commonly overused buzzwords, how reviewers and auditors may interpret vague phrasing, and why providers are encouraged to document findings more clearly. The piece is relevant to coders, billers, compliance staff, auditors, and clinicians who review E/M notes for completeness and clarity.
Why This Topic Matters
Ambiguous documentation can affect how E/M records are interpreted during audits and may contribute to level-selection or compliance concerns. Clear, specific wording helps support accurate review of provider intent and the documented examination or history.
What You Will Learn
- Why vague phrases in E/M notes can be problematic
- How unclear documentation may affect auditor interpretation
- Why clarity matters in documenting examination and history findings
- General alternatives that convey absence of findings more clearly
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Auditors
- Physicians and other providers
- Practice managers
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