General Surgery Coding Alert - 2019 Issue 1
Guidelines: Take These PFSH Tips, and Documentation Errors Will Be History
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Article Overview
This article explains documentation concepts tied to E/M history requirements, with emphasis on past medical, family, and social history and how current guidance distinguishes documentation types. It is intended for coders, auditors, billing staff, and clinicians who document evaluation and management encounters. The discussion also covers how recent Medicare final-rule changes relate to recording related history elements and provider review.
Why This Topic Matters
Accurate history documentation can affect whether the chart supports the intended level of evaluation and management service. Understanding the scope of required history elements and the impact of updated Medicare guidance helps reduce documentation errors and improve coding consistency.
Article Sections
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Tip 1: Know What Information Is Needed
Introduces the three major history areas used in E/M documentation and summarizes the kinds of information each area includes at a broad level.
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Tip 2: Know the Difference Between Pertinent and Complete
Explains the distinction between the two history documentation categories and discusses how broader CMS guidance addresses the amount of history needed in different service contexts.
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Tip 3: Know Why This Is Important
Describes why history completeness matters for supporting E/M level selection and references example office visit levels in that context.
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Tip 4: Know Whether the 2019 MPFS Final Rule Will Change Documentation Practices
Summarizes the effect of the 2019 Medicare final rule on documentation workflow and provider review for history-related elements.
What You Will Learn
- How E/M history documentation is organized into major categories
- How different documentation types are distinguished at a general level
- Why history documentation affects support for E/M level selection
- What the article says about Medicare final-rule changes and documentation workflow
Who Should Read This
- Medical coders
- Coding auditors
- Billing and reimbursement staff
- Physicians and other clinicians documenting E/M services
- Practice managers
Codes Discussed
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