E/M Coding Alert - 2013 Issue 25
EMR Issues: See How An EMR Upcoded This Visit by Two Levels
Subscribe or sign in to view the full article.
Article Overview
This article is aimed at medical coders, auditors, and compliance staff who review evaluation and management documentation generated with EMR templates. It discusses how note structure, documentation scope, and medical necessity can affect the apparent level of service in a follow-up visit, and it highlights the risk of relying on templated history and exam content without considering the overall encounter.
Why This Topic Matters
It helps readers recognize when EMR documentation may overstate the level of service and why the chart should be assessed in the context of the patient’s actual problem and management needs.
Article Sections
-
Review the note before reading the solution
Introduces the encounter and invites the reader to assess the documentation and the reported E/M level before seeing the explanation.
-
Find Out Where This Physician Went Awry
Explains the mismatch between the EMR-selected visit level and the overall complexity reflected in the chart, with emphasis on medical necessity and documentation scope.
-
What to look for
Describes the kinds of documentation patterns that may signal overdocumentation in a mostly resolved follow-up encounter.
-
Bottom line
Summarizes the broader caution about EMR templates and points readers toward related template-management guidance.
What You Will Learn
- How EMR templates can influence the apparent level of evaluation and management documentation
- Why medical necessity remains central when judging visit complexity
- What documentation patterns may suggest overdocumentation in a follow-up encounter
- Why template design can affect coding workflow and chart review
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician documentation reviewers
- Practice managers
Codes Discussed
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com