decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 3 (March)
Take carrier HPI advice with a healthy grain of salt
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Article Overview
This article discusses a coding and compliance question involving evaluation and management documentation, with emphasis on history of present illness documentation and how carrier guidance compares with CMS commentary and published documentation guidelines. It is aimed at coding professionals, compliance staff, and practices trying to align internal policy with Medicare-related guidance while understanding the practical audit implications of documentation attribution.
Why This Topic Matters
The topic affects how practices train staff, build compliance policies, and defend documentation during audits. It is relevant because the article highlights tension between local carrier advice and broader CMS guidance in the context of E/M history documentation.
What You Will Learn
- How the article frames the compliance issue involving history documentation in E/M services.
- Why carrier-level guidance may differ from broader CMS commentary.
- What kinds of documentation attribution questions practices should address in compliance planning.
- Why audit defensibility is a concern when history elements are recorded by staff other than the billing provider.
Who Should Read This
- Medical coders
- Coding managers
- Compliance officers
- Physician practices
- Audit and billing staff
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