Medicare Compliance & Reimbursement - 2018 Issue 7
Reader Question: Focus E/M Coding With These Rules
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Article Overview
This reader question addresses the basic structure of E/M history documentation and how current complaints, present illness details, and past-related history are separated in charting. It is intended for coders and clinical documentation staff who need a clearer understanding of how history elements support E/M code selection at a general level.
Why This Topic Matters
Accurate separation of current and past history elements is a foundational part of E/M documentation review and supports appropriate code level selection.
Article Sections
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Question
A reader asks how current and past conditions or symptoms should be categorized when reviewing an E/M chart.
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Answer
The response explains the broad relationship between current-patient information and past history within E/M documentation, and notes how history components factor into code level determination.
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For instance
An example is used to illustrate the difference between present-illness information and past history in the context of documentation review.
What You Will Learn
- How E/M history elements are grouped at a high level
- How current and past patient information are distinguished in documentation
- Why history components matter in E/M code selection
- How an illustrative example can clarify documentation categories
Who Should Read This
- Medical coders
- Clinical documentation staff
- Surgeons
- E/M auditors
- Billing professionals
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