General Surgery Coding Alert - 2018 Issue 8
Reader Question: Know Your Histories When Evaluating E/M Choice
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Article Overview
This article is a brief educational Q&A for medical coders and billing staff focused on evaluation and management (E/M) history elements. It clarifies the general relationship between current patient information and past history within chart documentation and describes why those distinctions matter for level selection.
Why This Topic Matters
Correctly understanding E/M history components is important for consistent chart review, documentation interpretation, and appropriate visit level selection in physician and surgical settings.
What You Will Learn
- How E/M history elements are organized conceptually
- Which parts of a note relate to current versus past patient information
- Why past history can still affect evaluation of current care
- How history documentation contributes to E/M level determination
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Physician office staff
- Surgeon documentation reviewers
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