Part B Coding Coach: Exceed Auditors' Expectations With This E/M History Level Guide

Why This Topic Matters

E/M history is a frequent audit focus, so understanding how the documentation is structured helps practices review notes consistently and reduce avoidable compliance risk.

Article Sections

1. Steer clear of the recheck pitfall

   Introduces the audit focus of the article and frames the discussion around E/M history documentation. It emphasizes the importance of reviewing patient notes element by element.

2. Always require a chief complaint

   Explains the role of the chief complaint in E/M history and why the documentation must reflect the reason for the visit. It also addresses common shortcomings in generic visit statements.

3. Look for these factors in patient timeline

   Reviews the history of present illness as a chronological account of the current problem. It outlines the broad types of information used to assess the level of history documentation.

4. Divide ROS into 3 categories

   Describes review of systems as part of the E/M history and distinguishes the general levels of scope used in documentation review. It also references the system categories recognized in CPT E/M guidance.

5. Decide PFSH scope with these tips

   Summarizes the past, family, and social history portion of E/M documentation and how its scope is assessed. The section focuses on the general history areas considered for reporting.

6. Beware this template trap

   Discusses risks associated with cloned or overly generic documentation templates. It highlights the need for patient-specific entries in history-related sections.

7. Tabulate your history level

   Brings the history elements together into a summary approach for determining the appropriate E/M history level. It reinforces the article's audit-oriented documentation review framework.