decisionhealth Newsletters, Coder Pink Sheets - 2008 Issue 8 (August)
E/M ‘check-up’ – You must understand history-taking to code accurately
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Article Overview
This premium article explains the history-taking component of E/M coding and why accurate documentation matters for office, hospital, and other patient encounters. It is aimed at coders and billing staff who need a clear understanding of the major history elements, how they are documented, and how they are used in broader E/M level selection.
Why This Topic Matters
Accurate history documentation is a key part of E/M code assignment and can affect whether a service is supported at the reported level. The article helps readers evaluate documentation quality and understand the general framework used in E/M history review.
Article Sections
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Four categories of history reviewed
Introduces the major parts of history documentation used in E/M reporting and explains the broad role each part plays in chart review.
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Select problem-focused, expanded, detailed or comprehensive
Summarizes the overall history levels used in E/M coding and discusses how encounter type and available documentation can affect classification.
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Choose the proper history for E/M levels
Presents a reference table showing the relationship between history categories and the different E/M history levels.
What You Will Learn
- How the history component fits into E/M documentation review
- Which broad history elements are considered during an encounter
- How history documentation supports overall E/M level selection
- Why history-taking documentation can vary by patient type and setting
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Clinical documentation reviewers
- GI practice staff
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