General Surgery Coding Alert - 2007 Issue 16
Part B Coding Coach: Test Your Review-Of-Systems Knowledge For More Accurate Claims
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Article Overview
This coding education article focuses on documentation-related issues that affect evaluation and management (E/M) service selection for office and other outpatient new-patient visits. It uses two Q&A scenarios to explain how review of systems, past/family/social history, and supporting documentation may influence code-level determination, with additional discussion of time-based reporting and physician review of nurse documentation. The article is aimed at coders and billers who want to better understand history requirements and documentation support for accurate claims.
Why This Topic Matters
Accurate history documentation is a common factor in E/M code selection and claim support. Understanding these documentation concepts can help billing and coding staff assess whether the record supports the reported visit level.
Article Sections
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2 expert scenarios help hone your E/M coding skills
Introduces the article’s two scenario-based questions and frames the discussion around outpatient E/M documentation and history requirements.
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Don't Let Language Barrier Keep You From Full HPI
Discusses a scenario involving limited patient communication, physician efforts to obtain history, and documentation considerations related to time and history gathering for a new patient visit.
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Ensure Your Doctor Signs the Nurse's Notes
Addresses use of nurse documentation in support of history elements and reviews the general relationship between ROS, PFSH, and new-patient E/M level selection.
What You Will Learn
- How review of systems and PFSH documentation relate to outpatient E/M service selection
- How supporting notes from nursing staff may be incorporated into physician documentation review
- How scenario-based documentation issues can affect history completeness for new-patient visits
- General considerations for time-based reporting and non-face-to-face work in E/M coding
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle staff
- Physician office staff
- Compliance staff
Codes Discussed
Code Ranges Discussed
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