Don’t overlook it: History and physical exam still count for office visits

Why This Topic Matters

The topic matters because office visit documentation practices affect clinical record quality, claim support, and workflow. Understanding the broader expectations helps practices align clinician documentation with billing and continuity-of-care needs.

Article Sections

1. Overview of the documentation changes

   Introduces the updated office visit documentation approach and its impact on how history and examination fit into evaluation and management reporting.

2. Changes are sowing confusion

   Summarizes the questions raised by the shift in documentation expectations and the perspectives shared during a national symposium.

3. Ground rules for documentation

   Describes the general expectations for documenting a medically appropriate history and examination, along with contractor guidance on scope and medical necessity.

4. Resources

   Lists external references and training materials related to the topic.