Reader Question: Include Chart Review in E/M

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Note:  The following article synopsis was NOT provided by AAPC. It was created by Find-A-Code/innoviHealth.

Article Overview

This reader Q&A addresses chart review and record review in the context of evaluation and management (E/M) coding for physician office services. It explains the general treatment of reviewing older medical records as part of the visit work, discusses how summarizing records can affect medical decision-making, and notes how related data elements may influence selection of a higher-level E/M service. The article is aimed at coders and billers who need guidance on physician documentation, E/M leveling, and Medicare-related data considerations.

Why This Topic Matters

Reviewing records is a common part of patient encounters, and understanding how that work fits into E/M coding helps avoid unbundling errors and supports appropriate level selection.

What You Will Learn

  • How record review is treated in the context of E/M services
  • How summarizing chart information can relate to medical decision-making
  • How related data elements may affect higher-level E/M service selection
  • How Medicare-related points for history summarization are described in the article

Who Should Read This

  • Medical coders
  • Medical billers
  • Physician office staff
  • General surgery practices

Codes Discussed


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