decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 6 (June)
No credit for reference to prior E/M exams
Subscribe or sign in to view the full article.
Article Overview
This article addresses evaluation and management documentation practices and clarifies the difference between history elements and exam elements when clinicians look back to prior records. It is aimed at coders, auditors, and clinicians who document E/M services and need a compliance-oriented understanding of what can and cannot be carried forward from earlier encounters. The discussion focuses on general documentation principles, the role of prior notes, and why workflow tools may help improve efficiency without compromising current-visit documentation.
Why This Topic Matters
Understanding the boundaries of prior-note reference is important for compliant E/M coding, accurate documentation, and avoiding unsupported level elevation based on outdated information. The article helps readers recognize where documentation continuity is allowed and where a current, encounter-specific record is expected.
What You Will Learn
- How E/M documentation principles distinguish history elements from exam elements
- When prior documentation may be referenced for current encounter support
- Why current-visit documentation remains important for exam-level support
- How documentation workflow tools can improve efficiency while maintaining compliance
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Practice managers
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com