E/M Coding Alert - 2016 Issue 7
Reader Question: You Can Carry Over PMFSH From Previous Encounter--to an Extent
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Article Overview
This reader Q&A discusses documentation practices for office and follow-up evaluation and management records, with emphasis on what can and cannot be carried forward from prior encounters. It is aimed at coders, billers, auditors, and clinicians who work with E/M documentation and EHR templates. The article covers general guidance on history documentation, physical exam documentation, and concerns about cloned notes in payer review.
Why This Topic Matters
Documentation consistency affects whether an E/M service can be supported on audit, especially when EHR templates or copy-forward habits create uneven records across history and exam sections.
What You Will Learn
- How follow-up encounter documentation is treated in E/M records
- What kinds of prior-history information may be carried forward in general terms
- Why exam documentation must be supported for each encounter
- Why copied or cloned note content can create audit risk
Who Should Read This
- Coders
- Billers
- Auditors
- Physicians
- E/M documentation staff
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