General Surgery Coding Alert - 2019 Issue 4
Reader Question: Go Beyond MDM to Interpret E/M Level
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Article Overview
This article addresses a reader question about evaluation and management (E/M) leveling when communication with a deaf patient involves a family member interpreter. It explains the general documentation and medical decision-making (MDM) considerations involved, along with compliance and audit concerns that can arise in this kind of encounter. The piece is aimed at coders, billers, and clinicians who document office or other E/M services.
Why This Topic Matters
Understanding how to document encounters that involve interpreters helps support accurate E/M reporting while reducing audit and compliance risk. The article highlights why documentation quality and nondiscrimination concerns matter in everyday coding workflows.
Article Sections
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Question
Introduces the scenario involving a new patient encounter, communication support, and a question about E/M leveling.
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Answer
Discusses the documentation and compliance implications of using interpreter-related information in support of medical decision-making and E/M selection.
What You Will Learn
- How interpreter-facilitated communication can affect E/M documentation
- Why documentation support for medical decision-making matters
- What general compliance concerns may arise in disability-related encounters
- How audit risk can be affected by the way encounter information is documented
Who Should Read This
- Coders
- Billing staff
- Compliance professionals
- Clinicians documenting E/M services
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