decisionhealth Newsletters, Part B News - 2017 Issue 3 (March)
When patient comes from ER, watch HPI elements, medication management
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Article Overview
This premium article focuses on evaluation and management coding considerations for patients referred from or recently seen in the emergency department. It addresses documentation questions around history elements, risk assessment, and medication management in the context of office or follow-up care. The piece is aimed at coders and documentation specialists who need to interpret common charting scenarios without overstepping into unsupported assumptions.
Why This Topic Matters
These documentation choices can affect E/M level selection and risk scoring, so understanding the article helps readers evaluate whether their coding approach aligns with the record.
What You Will Learn
- How emergency department documentation may affect subsequent E/M history review
- How HPI elements are discussed in relation to symptom and location documentation
- How medication-related management is considered in risk assessment
- How coders may approach ambiguous documentation in follow-up care
Who Should Read This
- Medical coders
- Coding auditors
- Documentation specialists
- E/M coders
- Practice managers
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