Part B Coding Coach: Bolster ED History Documentation With These 10 Tips

Why This Topic Matters

Emergency department coders and providers need documentation that supports the reported E/M level and withstands audit review. This article helps readers understand the broad documentation areas that affect history completeness and why those elements are important for accurate claim reporting.

Article Sections

1. Tip 1: Know That E/M Guidelines Might Change in a Few Years

   Discusses upcoming and historical E/M guideline changes and the need to prepare documentation practices accordingly.

2. Tip 2: Use Caution When Carrying Over Chief Complaint

   Covers the importance of documenting a chief complaint and the risks of relying on copied or incomplete information.

3. Tip 3: Recognize HPI’s Influence on Code Selection

   Explores the role of the history of present illness in evaluating the completeness of the record.

4. Tip 4: Know the Eight HPI Elements

   Summarizes the standard elements used when reviewing the HPI portion of a note.

5. Tip 5: Understand the Depth of Each HPI Element

   Walks through the major HPI element categories and discusses the level of detail expected in documentation.

6. Tip 6: Understand HPI With This Example

   Presents an illustrative emergency department scenario used to show how HPI elements may appear in practice.

7. Tip 7: Know What to Do When HPI Isn’t Obtainable

   Addresses situations where a complete HPI cannot be obtained and the need to document limiting circumstances.

8. Tip 8: Add More Detail Beyond the Diagnosis in the ROS

   Discusses documentation expectations for the review of systems and avoiding overly general entries.

9. Tip 9: Don’t Overuse “All Other Systems Negative”

   Reviews cautionary points about broad ROS phrasing and when it may be inappropriate.

10. Tip 10: Watch out for “Not Pertinent” PMFSH

    Covers documentation concerns involving past medical, family, and social history language.

11. Tip 11: Choose History Level Based on Lowest Section

    Explains that the overall history level depends on the least complete documentation area.