E/M Coding Alert - 2001 Issue 9
Reader Question: Subsequent Hospital Visits
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Article Overview
This reader Q&A discusses documentation for subsequent hospital visits, with emphasis on how interval history is interpreted in the context of evaluation and management coding. It is aimed at coders, auditors, and clinicians who need a clearer understanding of what supporting documentation is expected when reporting ongoing inpatient care. The article also addresses general considerations for selecting an appropriate service level based on documented patient status and response to treatment, and it notes when more intensive services may need to be considered.
Why This Topic Matters
Subsequent hospital care coding depends heavily on documentation quality and the patient’s status since the prior assessment. Understanding how interval history is documented helps support accurate E/M level selection and reduces the risk of unsupported reporting.
What You Will Learn
- How interval history is used in subsequent hospital care documentation
- What types of record review are part of subsequent hospital care
- How documentation supports the reported level of subsequent inpatient service
- How patient response to therapy factors into ongoing hospital care assessment
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation staff
- Revenue cycle professionals
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