General Surgery Coding Alert - 2007 Issue 10
CODING & COMPLIANCE: Don't Turn Your E/M Claims Into Audit Bait
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Article Overview
This article explains compliance considerations for evaluation and management documentation, focusing on how history elements are recorded and reviewed in relation to payer scrutiny. It is written for coders, compliance staff, and clinicians who need to understand documentation sufficiency, duplication concerns, and the general audit implications of E/M claims.
Why This Topic Matters
E/M documentation is a common source of audit exposure, and this piece highlights why careful history documentation matters for compliance and claim support.
What You Will Learn
- How evaluation and management history documentation is evaluated at a high level
- Why duplicated documentation can create compliance concerns
- How audit scrutiny relates to the depth of patient questioning
- What general factors distinguish limited from more detailed history gathering
Who Should Read This
- Medical coders
- Coding compliance staff
- Physicians
- Practice managers
- Billing professionals
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