General Surgery Coding Alert - 2013 Issue 2
Reader Question: Scour for Details Before Coding
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Article Overview
This article addresses a documentation question involving an established patient office visit and a physician letter sent back to a referring doctor. It is intended for coders and billing staff who review chart support for evaluation and management reporting and want to understand the general documentation elements discussed in the article.
Why This Topic Matters
It helps readers assess whether alternative forms of documentation may be sufficient for office visit reporting and why chart completeness matters when supporting a submitted claim.
Article Sections
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Question
Introduces the documentation scenario and the reader’s concern about support for an established patient office visit claim.
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Answer
Discusses the types of documentation elements that may be relevant when evaluating whether the visit record supports the reported office visit.
What You Will Learn
- What kinds of documentation may be reviewed when evaluating an office visit record
- Why a letter to a referring physician may be relevant to documentation support
- How incomplete documentation can affect confidence in reported evaluation and management services
- The general documentation considerations discussed for established patient office visit reporting
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Revenue cycle professionals
- Physician office staff
Codes Discussed
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