decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 8 (August)
Understanding E/M: No credit for reference to prior exams
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Article Overview
This premium article discusses a common E/M documentation question involving whether prior exam documentation can be referenced to support the exam portion of a current encounter. It explains the broader documentation guidance for history elements, contrasts that with physical examination documentation, and frames the issue for coders, physicians, and documentation staff working with E/M services.
Why This Topic Matters
E/M documentation drives medical necessity and level selection, so understanding which parts of a record may rely on prior information is important for accurate, compliant coding and defensible audits.
What You Will Learn
- How E/M documentation guidance treats prior documentation for different history components.
- Why physical exam documentation is discussed differently from ROS and PFSH in the article.
- How coders and physicians can think about efficient documentation while staying aligned with E/M principles.
- What general documentation concepts underlie the distinction between history and exam elements.
Who Should Read This
- Medical coders
- Physicians
- Compliance staff
- Documentation improvement personnel
- Practice managers
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