Outpatient Facility Coding Alert - 2013 Issue 9
Reader Question: Comp History Is Not a Given
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Article Overview
This article addresses a common evaluation and management documentation issue: what to do when a clinician cannot obtain a full patient history because of the patient’s condition or mental status. It explains the general documentation expectation, notes that payer policies may vary, and discusses how this affects E/M coding for inpatient and emergency department encounters. The piece is aimed at coders, billers, auditors, and clinicians who document hospital and ED services.
Why This Topic Matters
Incomplete history documentation can affect E/M level assignment, audit risk, and claim defensibility. The article helps readers understand the documentation expectations around unavailable history and the need to record attempts to obtain information from other sources.
What You Will Learn
- How incomplete patient history can affect E/M documentation
- What general documentation guidance says when a history cannot be obtained
- Why payer-specific policy can matter in history-based code selection
- How attempts to gather history from other sources should be documented
- How inpatient and emergency department E/M documentation considerations can differ
Who Should Read This
- Professional coders
- Hospital coders
- Billing staff
- Clinical documentation specialists
- Physicians and other clinicians
- Compliance auditors
Codes Discussed
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