E/M Coding: Make Your Documentation Problems Ancient History

Why This Topic Matters

Incomplete history documentation can affect E/M level selection and claim support. Understanding payer expectations helps providers document appropriately when history is unobtainable and reduces avoidable denials or coding uncertainty.

Article Sections

1. Remember to Show the Reason

   Explains the need to document why history could not be obtained and to note attempts to gather information from other sources. It also addresses later documentation updates when information becomes available.

2. Don’t Always Default to Comprehensive History

   Discusses payer guidance rejecting the idea that inability to obtain history automatically permits a higher history level. It focuses on documentation expectations and attempts to supplement history from available sources.

3. Base E/M Level on Other Elements

   Covers how E/M level selection may rely on other documented elements when history is unavailable, especially for established patient office visits. It also notes that reporting approaches for other visit types and payer categories may differ.