decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 5 (May)
Don’t refer to prior E/Ms for credit
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Article Overview
This piece discusses evaluation and management documentation guidance for pediatric and other office-based encounters. It focuses on how prior visit documentation can be used for certain historical components, why that does not extend to other parts of the encounter record, and how physicians and coders can think about compliant documentation practices. The article is relevant to coders, auditors, compliance staff, and clinicians who prepare or review E/M documentation.
Why This Topic Matters
Understanding the boundaries of what can be carried forward from a prior encounter helps practices avoid documentation errors and supports compliant E/M reporting. The article also speaks to workflow and template design considerations that affect efficiency and record accuracy.
What You Will Learn
- How evaluation and management documentation guidance addresses use of information from prior encounters
- Which broad documentation components are discussed as potentially reusable versus those that are not
- Why documentation workflow and record design matter for compliant E/M charting
- How clinicians and coding staff can approach efficient documentation without sacrificing accuracy
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians
- Pediatricians
- Practice managers
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