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 principles related to whether prior exam information can be referenced for credit in a current encounter. It is aimed at coders and clinicians who work with E/M documentation guidelines and want to understand the distinction between history elements and exam elements, as well as the role of prior records in documentation support.
Why This Topic Matters
Understanding the boundaries of E/M documentation is important for accurate coding, compliant recordkeeping, and avoiding unsupported level selection based on prior exam documentation.
What You Will Learn
- How E/M documentation guidance distinguishes between history elements and exam elements.
- Why prior encounter documentation may be treated differently for some parts of the record than for others.
- What general documentation principles affect whether earlier records can support a current visit.
- How coders can frame compliant documentation concerns with physicians.
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Practice managers
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