Reader Question: Your Physician Has Various Ways to Document

Article Overview

This article addresses a coding and documentation question involving an established patient office visit and whether a referral letter can support evaluation and management reporting. It is aimed at medical coders, billers, and office staff who need to understand the documentation elements that may support outpatient E/M code selection. The discussion focuses on broad documentation requirements, the type of information that may appear in a letter, and why the format of the record is less important than the presence of required elements.