decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 7 (July)
No credit for reference to prior E/M exams
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Article Overview
This article discusses evaluation and management documentation guidance for established and current encounters, with emphasis on the limits of using prior visit documentation for credit in a new visit. It is written for coders, auditors, and clinicians who need to understand the difference between history elements that may be carried forward and the exam portion of an encounter. The piece frames the discussion around the 1995 and 1997 E/M documentation guidelines and general compliance considerations.
Why This Topic Matters
Understanding what may and may not be referenced from prior documentation helps prevent unsupported E/M leveling and promotes compliant, accurate visit records.
What You Will Learn
- How E/M documentation guidance treats prior visit documentation in relation to current encounter scoring
- Which parts of history documentation may be updated from earlier records under the guidelines
- Why the exam portion of an encounter is treated differently from history elements
- How documentation efficiency can be balanced with compliance and accurate recordkeeping
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Compliance professionals
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