tci Medicare Compliance & Reimbursement - 2013 Issue 16
Reader Question: Your Physician Has Various Ways to Document
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Article Overview
This article addresses a coding and documentation question involving an established patient office visit and whether a referral letter can support evaluation and management reporting. It is aimed at medical coders, billers, and office staff who need to understand the documentation elements that may support outpatient E/M code selection. The discussion focuses on broad documentation requirements, the type of information that may appear in a letter, and why the format of the record is less important than the presence of required elements.
Why This Topic Matters
Understanding what documentation can support an E/M service helps coders and providers evaluate whether a visit is reportable and whether the record is adequate for compliance review.
What You Will Learn
- What kinds of documentation may support an established patient office visit
- Which broad documentation elements are relevant to outpatient E/M reporting
- Why documentation format alone does not determine code support
- How incomplete documentation can affect the ability to report an E/M service
Who Should Read This
- Medical coders
- Medical billers
- Physician office staff
- Compliance staff
- Ob-gyn practice staff
Codes Discussed
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