Revenue Booster: Make Your History Documentation Word Perfect

Article Overview

This article explains common documentation pitfalls in evaluation and management history-taking and how to avoid them. It is aimed at coders, billers, auditors, and physicians who want to strengthen record quality for office and other E/M services. The guidance focuses on separating history from exam content, capturing patient-reported information clearly, avoiding duplicate documentation across history components, using patient-completed forms appropriately, and understanding documentation issues when a patient cannot provide a history.