Medicare Compliance & Reimbursement - 2016 Issue 14
Reader Question: Documentation Should Focus on Substance, Not Style
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Article Overview
This reader Q&A explains the documentation considerations behind selecting an established patient office evaluation and management code when the chart note is formatted as a letter to a referring physician. It is relevant to coders, billing staff, compliance teams, and clinicians who need to understand what general documentation elements are discussed in support of office visit coding and why note format alone is not the deciding factor.
Why This Topic Matters
Understanding documentation expectations helps organizations evaluate whether an E/M service is supported by the record, especially when provider documentation does not follow a standard office note template.
What You Will Learn
- What general types of documentation elements are discussed for supporting an established patient office visit code.
- How a letter-format note is considered in relation to E/M documentation support.
- Why the presence or absence of key visit components affects whether documentation can support the reported service.
- How this topic relates to established patient office visit coding documentation standards.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Compliance professionals
- Physicians and other providers
Codes Discussed
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