Medicare Compliance & Reimbursement - 2015 Issue 3
You Be the Coder: Can You Draw Elements of History and MDM From Anywhere In The Chart?
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Article Overview
This article is a coding discussion for emergency department documentation review. It focuses on how history, review of systems, past history, examination, and medical decision-making may be supported by the chart as a whole, and it also touches on reporting a central venous catheter insertion, ultrasound guidance, and linked diagnoses in the claim context. The piece is intended for coders who need to evaluate ED documentation completeness and understand the general reporting framework used in a complex encounter.
Why This Topic Matters
It helps coders and auditors assess whether chart documentation supports an ED visit level when the note is fragmented across the record. It also places the E/M discussion in the context of procedure and diagnosis coding used for acute care encounters.
Article Sections
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Case Presentation
Introduces the encounter context, the presenting complaint, and the clinical scenario being reviewed.
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History, Exam, and Procedure Documentation
Summarizes the charted clinical findings, the procedural note, and the supporting documentation discussed in the article.
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Coding Discussion and Reported Claim
Explains the general documentation issue being addressed and identifies the types of codes reported for the encounter.
What You Will Learn
- How documentation elements from different parts of the chart may support an ED E/M service
- How a procedure note and imaging support information are presented in the context of central venous access
- How the article frames the relationship between the clinical record and reported diagnosis coding
- How to recognize the general scope of an emergency department coding review article
Who Should Read This
- Medical coders
- Coding auditors
- Revenue cycle professionals
- Emergency department billing staff
- Clinical documentation review staff
Codes Discussed
Modifiers Discussed
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