General Surgery Coding Alert - 2012 Issue 13
Reader Question: Avoid Assumptions When History Is Undocumented
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Article Overview
This article discusses documentation and coding considerations for evaluation and management services when a patient history cannot be fully obtained. It explains the general documentation approach, notes the role of payer-specific guidance, and highlights the importance of recording attempts to gather history from other sources. The content is aimed at coders and clinicians who need to understand how incomplete history documentation can affect service selection and support.
Why This Topic Matters
Incomplete history documentation is a common issue in E/M coding, especially when patients cannot provide information themselves. Understanding what must be documented, and when other E/M components or payer rules may matter, helps support compliant code selection.
What You Will Learn
- How incomplete history documentation can affect E/M service selection
- Why documenting efforts to obtain history from other sources matters
- How payer-specific guidance may influence documentation review
- How E/M component selection may differ when history is unavailable
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation specialists
- Billing staff
Codes Discussed
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