General Surgery Coding Alert - 2020 Issue 2
Reader Question: Look to These Guidelines to Know Your History
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Article Overview
This brief reader Q&A explains how a common documentation phrase is viewed within the context of CPT evaluation and management history. It is aimed at coders, auditors, and clinicians who work with E/M documentation and need a general understanding of the history elements discussed in the article.
Why This Topic Matters
Accurate understanding of E/M history documentation supports compliant record review and helps distinguish between history categories used in coding workflows.
What You Will Learn
- How the article frames family history within CPT E/M history
- Which broad documentation concepts are compared in the discussion
- Why the wording used in history documentation can matter for review and auditing
- General cautions discussed for electronic medical record documentation practices
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinical documentation specialists
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