decisionhealth Newsletters, Part B News - 2021 Issue 7 (July)
Go to the source when you count review of external notes
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Article Overview
This article clarifies a documentation counting concept used in office visit medical decision-making under CPT guidance. It focuses on how to think about external notes, records, and other materials when they come from different organizations, groups, specialties, or facilities. The piece is aimed at coders, billers, and clinicians who need a better understanding of source-based counting for evaluation and management documentation.
Why This Topic Matters
Accurately identifying what constitutes a unique source can affect how office visit documentation is counted and interpreted. Understanding this concept helps coding and clinical staff apply CPT guidance consistently when reviewing outside records and notes.
What You Will Learn
- How external records and notes are framed within CPT guidance
- How the concept of a unique source is used in office visit documentation counting
- How source identity can vary across facilities, groups, and specialties
- Why office visit documentation review requires attention to where information originated
Who Should Read This
- Medical coders
- Medical billers
- Coding auditors
- Physicians
- Qualified health care professionals
- Practice administrators
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