Outpatient Facility Coding Alert - 2015 Issue 1
You Be the Coder: Rely on Note for Reason for Partial History
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Article Overview
This coding Q&A discusses documentation-based evaluation and management (E/M) reporting for established patient office visits when part of the history is incomplete due to emergent circumstances. It is aimed at coders and billing staff who need to understand how history, exam, and medical decision making are weighed in those visits and why physician documentation matters.
Why This Topic Matters
Incomplete histories can occur in urgent situations, and this article helps readers understand that visit selection depends on the recorded components of the encounter. It is relevant for anyone coding established patient office E/M services and reviewing chart documentation for support.
What You Will Learn
- How incomplete history documentation may be handled in an established patient visit
- How visit selection is tied to the documented components of the encounter
- Why physician note documentation is important when history cannot be fully obtained
- How established patient office E/M services are evaluated at a high level
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Compliance personnel
Codes Discussed
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