tci Medicare Compliance & Reimbursement - 2013 Issue 22
Reader Question: Comprehensive History Is Not a Given
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Article Overview
This article addresses a documentation and coding question for evaluation and management services when a complete patient history cannot be obtained directly. It explains the general documentation expectations, the role of information from other sources, and why payer policies and service setting can affect how the encounter is reported. The piece is intended for coders, billers, and clinical documentation staff reviewing inpatient and emergency department E/M records.
Why This Topic Matters
Accurate history documentation affects E/M level selection and compliance review. The article helps readers understand when incomplete patient-provided information may still support a reported service if the record shows appropriate efforts to obtain history from other sources and the applicable payer guidance is followed.
What You Will Learn
- How incomplete patient history documentation can affect E/M level selection
- What kinds of alternate sources may support historical documentation
- Why payer-specific guidance matters in these situations
- How setting and component requirements can influence code selection for E/M services
Who Should Read This
- Medical coders
- Medical billers
- Clinical documentation improvement staff
- Physicians and other E/M providers
Codes Discussed
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