Part B Revenue Booster: Boost Your Bottom Line With These 3 E/M Documentation Steps

Why This Topic Matters

Accurate history documentation can affect E/M level selection and overall coding completeness. The article is relevant for practices trying to improve documentation quality and support consistent office visit reporting.

Article Sections

1. Tip: Don't miss the endocrine system when you're tallying ROS

   Introduces the documentation focus of the article and the importance of capturing review of systems accurately in office visit coding.

2. Step 1: Create a Form

   Describes using structured documentation tools to support history capture and consistent office visit recordkeeping.

3. Step 2: Don't Overlook Systems

   Discusses review of systems documentation considerations and commonly overlooked body systems in the context of E/M office visits.

4. Keep in mind:

   Provides additional context about how symptom-related statements may relate to office visit history documentation.

5. Step 3: Don't Neglect PFSH

   Covers the broad components of past, family, and social history and their relevance to established patient documentation.

6. Keep in mind:

   Adds a reminder about how established patient questions may differ across past, family, and social history elements.