decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 5 (May)
Ensure your E/M claims include three patient history areas
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Article Overview
This article reviews core evaluation and management (E/M) history documentation topics, focusing on the three main history areas, what belongs in each, and common omissions that affect claim support. It is intended for coders, auditors, and providers who need a practical reminder about history documentation expectations and the general service levels referenced in the discussion.
Why This Topic Matters
Accurate history documentation is a frequent source of E/M claim errors, and missing elements can affect whether the record supports the billed service level. The article is useful for practices that want to strengthen provider documentation habits and reduce coding risk.
What You Will Learn
- The three main components of a complete patient history for E/M documentation
- What broad types of details are captured in the present illness narrative
- What the review of systems and past family and social history generally cover
- Common documentation omissions that can affect E/M claim support
- How history documentation relates to selected office visit and consultation service levels
Who Should Read This
- Coders
- Coding auditors
- Physicians
- Practice managers
- Clinical documentation staff
Codes Discussed
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