Medicare Compliance & Reimbursement - 2013 Issue 7
Reader Question: E/M Format Shouldn't Matter
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Article Overview
This reader question explores documentation expectations for established patient office visits when the only record is a letter sent back to a referring physician. It is aimed at coders, billing staff, auditors, and clinical documentation reviewers who need to understand how documentation format relates to evaluation and management reporting. The article discusses the types of information that may be present in correspondence and the general documentation sufficiency issues involved.
Why This Topic Matters
Understanding documentation sufficiency helps prevent unsupported E/M reporting and reduces compliance risk when providers use nontraditional note formats.
What You Will Learn
- How correspondence may be evaluated as documentation for an office visit
- What types of information are relevant to supporting established patient E/M reporting
- Why documentation format alone does not determine whether a service is supportable
- How insufficient documentation can affect code support
Who Should Read This
- Medical coders
- Billing staff
- Compliance auditors
- Documentation reviewers
- Physicians
Codes Discussed
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