ED Coding & Reimbursement Alert - 2012 Issue 34
Quick Quiz Answers: Evaluate Your Own E/M Coding Skills With 3 Test Answers
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Article Overview
This premium article is a brief E/M education piece that addresses common documentation and service-level selection questions. It is intended for coders, auditors, billers, and clinicians who work with outpatient or office-based E/M reporting and want a clearer understanding of how documentation guidelines and medical necessity affect coding decisions. The discussion focuses on general documentation standards, comparing guideline approaches, and avoiding common pitfalls in automated or high-level E/M selection.
Why This Topic Matters
E/M coding is highly dependent on documentation quality and accurate interpretation of guidelines. Understanding the topics covered here can help reduce audit risk, improve compliance, and support more consistent code selection across encounters.
Article Sections
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Answer 1
Discusses documentation of prior history information across encounters and the need to show review and update of earlier documentation. The section focuses on general E/M recordkeeping expectations.
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Answer 2
Compares the use of the two main E/M documentation guideline sets and notes that practices may follow the approach most suitable to their documentation style. It also addresses how guideline selection can vary by encounter.
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Answer 3
Explores the relationship between service level selection, medical necessity, and automated EHR-based coding. The section also highlights concerns about overcoding and the distinction between medical necessity and medical decision making.
What You Will Learn
- How prior history documentation may be handled across visits
- How clinicians and coders think about the available E/M documentation guideline sets
- Why medical necessity remains central to E/M level selection
- How automated documentation tools can affect E/M coding compliance
- How medical decision making differs from medical necessity in E/M reporting
Who Should Read This
- Medical coders
- Coding auditors
- Physician office staff
- Billing professionals
- Clinicians documenting E/M services
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