Medicare Compliance & Reimbursement - 2014 Issue 6
Reader Question: You Don't Get A Pass on History Portion of E/M
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Article Overview
This reader Q&A explains documentation considerations for evaluation and management (E/M) services when a patient is unable to communicate history due to condition or circumstance. It addresses how history components may be supported, why payer policies matter, and how Medicare contractors and other payers may interpret documentation under the 1997 guidelines. The article is relevant to coders, billers, auditors, and clinicians who document inpatient or other E/M encounters involving limited patient input.
Why This Topic Matters
Accurate E/M leveling depends on documentation, and inability to obtain history does not automatically change the exam component. Understanding the documentation expectations and payer-specific policies helps avoid unsupported coding and claim denials.
What You Will Learn
- How documentation rules apply when a patient cannot provide history during an E/M encounter.
- Why payer policies can affect whether a history level is supported.
- What kinds of circumstances may need to be documented when history cannot be obtained.
- How contractor and insurer guidance can influence documentation expectations.
Who Should Read This
- Medical coders
- Medical billers
- Clinical documentation staff
- Compliance/audit professionals
- Physicians and other providers
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