E/M Errors: Know the Top Pitfalls of E/M Coding

Why This Topic Matters

Accurate E/M coding depends on documentation that supports the service reported. This article is relevant to anyone responsible for reviewing provider notes, reducing billing errors, or monitoring higher-level E/M reporting.

Article Sections

1. Error 1: Watch for Incomplete or Insufficient Documentation

   Discusses documentation problems that can affect whether a service is supported in the record. Includes general review and education practices for improving documentation quality.

2. Error 2: Spot Frequent Reporting of Highest Codes in a Range

   Covers concerns about routinely reporting the top level of a service range and the need for documentation to support the reported level. Also addresses broader review of E/M documentation patterns and time-based reporting considerations.