Outpatient Facility Coding Alert - 2003 Issue 6
Reader Question: Give Docs a Last-Chance Look-Over
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Article Overview
This reader question addresses documentation review practices for evaluation and management coding, with emphasis on review of systems documentation, physician addenda, and ethical handling of incomplete records. It is intended for coders, compliance staff, and clinicians who work with office or emergency department documentation and want general guidance on chart review workflow and documentation integrity.
Why This Topic Matters
Accurate documentation review affects E/M claim support, compliance risk, and the integrity of the medical record. The article helps readers understand the boundary between correcting incomplete documentation and improperly adding information after the fact.
Article Sections
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Question
A reader describes a recurring documentation issue involving review of systems completion for higher-level E/M claims and asks about the ethics of returning charts for additional review.
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Answer
The response discusses appropriate handling of incomplete records, the role of physician addenda, and the general timing of chart review before claims are submitted.
What You Will Learn
- How documentation review relates to E/M claim support
- When chart addenda are generally considered appropriate
- Why completeness of review of systems documentation matters
- How to approach physician education on documentation habits
Who Should Read This
- Medical coders
- Compliance staff
- Physicians
- Billing staff
Codes Discussed
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