Outpatient Facility Coding Alert - 2011 Issue 3
Clip And Save: Use This Simple Tool to Ensure You Cover Every System Possible
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Article Overview
This short article focuses on documentation support for evaluation and management visits, with emphasis on using a simple template to help capture review-of-systems information consistently. It is relevant to physicians, coders, and billing staff who want to understand general charting practices that support E/M level selection and documentation review. The article also notes considerations around patient-completed templates and the need for patient-specific documentation review.
Why This Topic Matters
Accurate encounter documentation affects evaluation and management coding accuracy and claim support. A practical template can help practices reduce missing review-of-systems information and improve documentation consistency.
What You Will Learn
- Why review-of-systems documentation matters in evaluation and management visits
- How a template can support more complete encounter documentation
- General considerations for patient-completed documentation forms
- The importance of documenting that documentation was reviewed with the patient
Who Should Read This
- Physicians
- Medical coders
- Medical billers
- Practice managers
- Compliance staff
Codes Discussed
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