decisionhealth Newsletters, Part B News - 2018 Issue 8 (August)
7 tips to overcome E/M coding pitfalls amid increased auditing activity
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Article Overview
This article explains common evaluation and management documentation issues that can trigger audit scrutiny in office-based coding. It is aimed at coders, auditors, and billing staff who need a high-level understanding of how documentation frameworks, history elements, chief complaint, HPI, consistency across records, and time-based reporting are discussed in the context of compliance and revenue protection.
Why This Topic Matters
The piece is relevant because documentation problems can affect code support, increase audit exposure, and contribute to claim denials or revenue loss. It helps readers identify the broad areas where E/M records are most often reviewed for completeness and consistency.
What You Will Learn
- The main documentation areas that commonly create E/M audit risk
- How broad E/M history components are discussed in relation to office visits
- Why record consistency and documentation completeness matter in auditing
- When time-based reporting is discussed as a documentation consideration
Who Should Read This
- Medical coders
- Billing staff
- Compliance auditors
- Practice managers
- Physician office staff
Codes Discussed
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