decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 4 (April)
9 ways to improve your providers' history documentation
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Article Overview
This article explains common pitfalls and improvement strategies for provider history documentation in evaluation and management (E/M) services. It is aimed at managers, auditors, coders, and physician educators who want to better understand how history documentation affects audit risk, payment accuracy, and compliance with E/M documentation guidance. The discussion focuses on general history components, documentation habits, and carrier-sensitive practices without replacing the full premium guidance.
Why This Topic Matters
History documentation is a frequent source of E/M audit findings and can influence whether a service is supported at the intended level. Understanding common documentation weaknesses helps organizations reduce downcoding risk, improve consistency, and support compliant claims submission.
Article Sections
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Overview of E/M history documentation issues
Introduces the documentation topic and explains why history is a frequent focus in E/M audit activity. Sets up the article’s emphasis on common errors and improvement opportunities.
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Review of systems and past, family, social history
Covers the main history components and broad documentation concerns related to system review and prior history information. Discusses recurring chart review problems and how they affect overall history level.
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Documentation practices and audit considerations
Addresses general practices that can influence how reviewers interpret documentation, including wording choices, repeat-visit documentation, and the use of prior information. Also notes broader compliance and payer-review concerns.
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Templates and incomplete history situations
Discusses use of templates for inpatient documentation and handling situations where a complete history cannot be obtained. Focuses on practical documentation support and record completeness.
What You Will Learn
- Why history documentation is a common focus in E/M audits
- Which broad history components are discussed as frequent problem areas
- How documentation wording can affect interpretation during review
- What general practices may help support more complete history records
- How documentation is addressed when a history cannot be fully obtained
Who Should Read This
- Physician office managers
- Coding professionals
- Clinical documentation auditors
- Physician educators
- Revenue cycle staff
Codes Discussed
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