Leave the word ‘refill’ out of documentation

Article Overview

This article discusses documentation practices for office visits when medication refill requests are involved, with a focus on evaluation-and-management billing and claim denial risk. It is aimed at coders, billers, compliance staff, and clinicians who document patient encounters. The article covers how refill language can affect the reported reason for visit, why that matters for office visit claims, and the importance of aligning documentation with the clinical content of the encounter.