decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 6 (June)
No credit for reference to prior E/M exams
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Article Overview
This article discusses evaluation and management documentation guidance for using prior encounter notes in a current visit. It is written for coders, physicians, and compliance-minded staff who need to understand the general documentation principles behind reviewable history elements versus current exam documentation, and how those principles affect E/M level support. The discussion stays focused on policy interpretation and practical documentation workflow considerations rather than on specific patient cases.
Why This Topic Matters
Understanding the limits of referencing prior documentation helps prevent unsupported E/M level selection and supports compliant medical record practices. The article is relevant to anyone training providers or auditing documentation for current visit support.
What You Will Learn
- The general distinction between current encounter documentation and information referenced from prior visits
- Which broad E/M documentation components are discussed as exceptions to re-documentation
- Why documentation workflow and record review practices matter for compliant E/M support
- How efficiency concerns intersect with accurate current-visit documentation
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Practice administrators
- Compliance staff
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