E/M Coding Alert - 2019 Issue 7
Reader Question: How Do You Support Caveat Intent?
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Article Overview
This reader Q&A explains a documentation topic relevant to emergency department coding and compliance: how to support an unobtainable history under CMS-related review and documentation standards. It discusses the role of the physician’s note, the broader medical record, and references to the 1995 documentation guidelines. The article is aimed at coders, auditors, and clinicians who need to understand what general documentation support is expected when patient history cannot be gathered directly.
Why This Topic Matters
Clear documentation support can affect whether an auditor accepts the record as adequately substantiated. The article helps readers understand the general compliance concern and the importance of documenting why information could not be obtained and what sources were consulted.
Article Sections
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Question
Introduces the documentation and audit concern being raised about inability to obtain patient history in an emergency department setting.
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Answer
Summarizes guidance tied to documentation standards and discusses the general importance of documenting the reason history was unavailable and the sources reviewed.
What You Will Learn
- How documentation support is framed when patient history cannot be obtained
- Why the broader record may be discussed in audit review
- How documentation guidelines relate to unsupported history scenarios
- Why explicit physician documentation is emphasized for compliance purposes
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Emergency department clinicians
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