ED Coding & Reimbursement Alert - 2019 Issue 5
Documentation: Test Your E/M Coding Savvy with These 3 Questions
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Article Overview
This premium article is a practical E/M coding discussion for coders, auditors, and compliance staff who want to test documentation-based coding judgment in office and outpatient settings. It focuses on common problem scenarios for established and new patient visits, the relationship between documented history, examination, and medical decision making, and how payer expectations can affect evaluation-and-management level selection. The article is designed to help readers recognize when documentation supports a reported service level and when additional clarification or internal auditing practices may be needed.
Why This Topic Matters
Accurate E/M leveling affects claim integrity, audit readiness, and consistent application of documentation standards. The article highlights situations where coders may be uncertain and shows why payer-specific interpretation and clear internal reference materials matter.
Article Sections
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Introduction
Sets up the article as a short self-check on evaluation-and-management documentation and coding judgment. Introduces the theme of unusual situations that can make service-level selection difficult.
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Is Two out of Three so Bad?
Discusses a scenario involving an established patient office/outpatient visit and the relationship between documented visit components and reported service level. Also addresses the role of payer expectations in evaluating whether documentation supports the claim.
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Should You Play It Safe?
Covers an internal audit scenario in which coders may undercode when documentation is uncertain. Focuses on the need for auditing tools, payer references, and consistent internal policies for E/M review.
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Can This Visit Be Coded at All?
Reviews a new patient visit scenario where the available documentation raises questions about whether a higher service level is supported. Addresses the need to understand how history, examination, and medical decision making work together in new patient coding.
What You Will Learn
- How office and outpatient E/M documentation is evaluated in common coding scenarios
- Why established patient and new patient visits are not assessed the same way
- How payer-specific documentation expectations can influence coding reviews
- Why internal audit tools and written references are important for coders
- How coders can think about documentation completeness before assigning a service level
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Billing professionals
- Practice administrators
Codes Discussed
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