Outpatient Facility Coding Alert - 2007 Issue 14
CODING & COMPLIANCE: Look For Questions That Go Beyond The Patient's 'Chief Complaint'
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Article Overview
This article explains compliance concerns tied to evaluation and management documentation, especially how clinicians’ questions and charted history are evaluated in relation to the presenting problem. It is relevant to coders, auditors, and physician practices that document E/M services and want to understand general guidance on history elements, duplicate statements, and payer review risk.
Why This Topic Matters
Documentation choices in E/M visits can affect audit exposure and whether a payer views the record as medically necessary and supportable. The article helps readers understand the broader compliance implications of charting practices tied to history-taking and duplicated information.
What You Will Learn
- How E/M documentation is evaluated from a compliance perspective
- Why history-taking depth matters in chart review
- What kinds of documentation practices may raise audit concerns
- How duplicate charted information can affect payer scrutiny
Who Should Read This
- Medical coders
- Coding compliance professionals
- Physician office staff
- Auditors
- Revenue cycle staff
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