decisionhealth Newsletters, Coder Pink Sheets - 2008 Issue 9 (September)
When you have to use E/Ms: History-taking 101
Subscribe or sign in to view the full article.
Article Overview
This article explains how ophthalmology coders and clinicians should understand the history portion of E/M documentation when E/M services are used instead of eye codes. It is aimed at coding professionals, auditors, and ophthalmology practices that need a clearer view of the documentation elements used to support E/M levels, including general guidance on chief complaint, history of present illness, review of systems, and past, family, and social history.
Why This Topic Matters
Accurate history documentation is central to supporting the level of E/M service and to reducing audit risk. The article helps readers recognize the broad documentation areas that affect E/M selection in ophthalmology settings.
Article Sections
-
E/M coding in ophthalmology
Introduces why E/M services may be used in ophthalmology settings and frames the documentation focus of the article.
-
Four categories of history reviewed
Explains the major history components that are reviewed when assessing E/M documentation for a visit.
-
Select problem-focused, expanded, detailed or comprehensive
Describes how the collected history information is used within the broader E/M leveling process and notes special documentation circumstances.
What You Will Learn
- How the history component fits into ophthalmology E/M documentation
- What broad types of information are reviewed during history-taking
- Why documentation completeness matters for E/M audit support
- How special situations can affect history capture in the medical record
Who Should Read This
- Ophthalmology coders
- Medical coders
- Billing staff
- Compliance auditors
- Ophthalmology practice managers
- Clinicians documenting E/M services
Codes Discussed
Code Ranges Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com