Outpatient Facility Coding Alert - 2014 Issue 5
You Be the Coder: Back Up and Master E/M Levels of Service
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Article Overview
This premium article discusses evaluation and management (E/M) leveling for office or other outpatient visits, with emphasis on the role of history documentation in supporting visit selection. It is aimed at coders, billers, and clinic documentation staff who want to understand the broad framework for assessing service level and the history components involved. The article covers general history elements, the relationship between history and overall E/M level, and the circumstances in which higher-level office/outpatient visit categories are discussed.
Why This Topic Matters
Accurate E/M leveling depends on complete documentation and correct interpretation of the history, exam, and medical decision-making framework. This topic matters because misunderstandings about one element of the history can lead to coding uncertainty and inconsistent reporting.
What You Will Learn
- How history documentation relates to E/M service level selection
- What broad components are considered in determining an office/outpatient visit level
- How the article frames the relationship between HPI and the overall history component
- Which general history elements are part of the E/M framework
Who Should Read This
- Medical coders
- Billing staff
- Clinical documentation specialists
- Physician office staff
Codes Discussed
Code Ranges Discussed
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