Medicare Compliance & Reimbursement - 2020 Issue 7
Reader Questions: Focus Comprehensive History Requirements
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Article Overview
This reader Q&A explains how documentation completeness is assessed when comparing different levels of history for office visit coding. It is aimed at coders, auditors, and revenue cycle staff who review provider notes for evaluation and management documentation support. The article focuses on the broad history elements involved and how the documented components are compared against the requirements for a higher-level versus lower-level history.
Why This Topic Matters
Understanding history documentation requirements helps coding staff evaluate whether a visit note supports the intended level of service and identify when documentation falls short of the needed standard.
What You Will Learn
- How office visit history elements are evaluated at a high level
- What documentation components are compared when reviewing a note for history level support
- How documentation completeness affects review of visit level selection in general terms
- The difference between broader and more limited history documentation categories
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Revenue cycle staff
- Physician documentation reviewers
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