tci Medicare Compliance & Reimbursement - 2013 Issue 3
Revenue Booster: Make Your History Documentation Word Perfect
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Article Overview
This article explains common documentation pitfalls in evaluation and management history-taking and how to avoid them. It is aimed at coders, billers, auditors, and physicians who want to strengthen record quality for office and other E/M services. The guidance focuses on separating history from exam content, capturing patient-reported information clearly, avoiding duplicate documentation across history components, using patient-completed forms appropriately, and understanding documentation issues when a patient cannot provide a history.
Why This Topic Matters
History documentation can affect E/M code selection and whether the medical record supports the level of service billed. Clear, complete history entries help reduce undercoding, support compliance, and make chart review easier.
What You Will Learn
- How history documentation differs from the physical exam in E/M services
- Why patient-reported details should be recorded clearly in the chart
- How to avoid duplicating the same history information in multiple places
- How patient-completed history forms fit into the documentation process
- What documentation considerations apply when a patient cannot provide a history
Who Should Read This
- Medical coders
- Billing professionals
- Physicians
- Clinical documentation staff
- Compliance auditors
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