Outpatient Facility Coding Alert - 2018 Issue 5
Reader Question: See if History is Present or Past
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Article Overview
This article addresses a common question for people learning E/M coding: how current symptoms and conditions differ from past medical, family, and social history in documentation. It is aimed at coders and clinicians who need a clearer understanding of history components and how they fit into E/M history level selection.
Why This Topic Matters
Correctly distinguishing present versus past history supports more accurate E/M documentation review and helps readers understand why history components matter in code selection.
What You Will Learn
- How E/M history elements are categorized into current and past information
- How chief complaint, history of present illness, review of systems, and past/family/social history relate to documentation
- Why past history can be relevant to current treatment context
- How history documentation contributes to E/M history level selection
Who Should Read This
- Medical coders
- Auditors
- Physicians
- Surgeons
- Clinical documentation staff
- E/M coding learners
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