Ask Joan: No credit for reference to prior E/M exams

Article Overview

This Q&A column explains a common evaluation and management documentation question about referencing prior visit records during a current encounter. It is aimed at coders, auditors, compliance staff, and clinicians who document office or hospital encounters under the E/M guidelines. The article discusses the distinction between history and exam documentation, the limited circumstances in which prior ROS and PFSH documentation may be referenced, and practical workflow ideas for making documentation efficient while staying compliant.