General Surgery Coding Alert - 2011 Issue 17
E/M Documentation: Documenting 'All Others Negative' Could Cost Your Physician $87 Per Visit
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Article Overview
This article explains how review-of-systems documentation practices can affect evaluation and management claim review, especially when a payer or MAC does not accept broad shorthand statements as sufficient documentation. It is aimed at physicians, coders, auditors, and compliance staff who need to understand how documentation patterns may affect chart support, audit vulnerability, and potential downcoding risk. The discussion focuses on general documentation standards, payer variation, and the importance of checking local guidance before relying on common charting shortcuts.
Why This Topic Matters
Documentation habits that seem acceptable under general E/M guidance may still fail under specific payer policies, creating avoidable audit exposure and reimbursement reduction. Understanding the documentation expectations discussed in the article can help practices reduce denials, downcoding, and compliance risk.
Article Sections
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Require the Basics
Discusses general review-of-systems documentation expectations, differences between broad E/M guidance and payer-specific requirements, and why local carrier policies matter.
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Stem Overuse With Common Sense
Addresses documentation patterns that may raise audit concerns and the importance of aligning the scope of documentation with the clinical context.
What You Will Learn
- How review-of-systems documentation can affect E/M claim review
- Why payer-specific guidance may differ from general documentation standards
- What kinds of documentation patterns may increase audit scrutiny
- How local policies can influence whether shorthand charting is acceptable
Who Should Read This
- Physicians
- Medical coders
- Medical auditors
- Compliance staff
- Practice administrators
Codes Discussed
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