DecisionHealth, DecisionHealth - 2006 Issue 6 (June)
How far back in “history” should an E/M coder go?
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Article Overview
This article discusses a coding and compliance question about the freshness of patient history information used in E/M documentation. It is relevant to coders, auditors, and practice staff who maintain history forms and internal documentation policies, with emphasis on general E/M documentation guidance and operational considerations.
Why This Topic Matters
Keeping history information current can affect documentation quality, audit readiness, and practice policy consistency. The article helps readers understand the documentation issue at a high level without replacing the need to review formal guidelines and local practice policies.
What You Will Learn
- Why current patient history documentation matters in E/M workflows
- How practices may approach internal policies for updating history information
- What the article says about documentation currency and audit concerns at a general level
- Why this topic matters for coding, compliance, and liability awareness
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician practice managers
- Clinical documentation staff
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