EMR Issues: See How An EMR Upcoded This Visit by Two Levels

Why This Topic Matters

It helps readers recognize when EMR documentation may overstate the level of service and why the chart should be assessed in the context of the patient’s actual problem and management needs.

Article Sections

1. Review the note before reading the solution

   Introduces the encounter and invites the reader to assess the documentation and the reported E/M level before seeing the explanation.

2. Find Out Where This Physician Went Awry

   Explains the mismatch between the EMR-selected visit level and the overall complexity reflected in the chart, with emphasis on medical necessity and documentation scope.

3. What to look for

   Describes the kinds of documentation patterns that may signal overdocumentation in a mostly resolved follow-up encounter.

4. Bottom line

   Summarizes the broader caution about EMR templates and points readers toward related template-management guidance.