Outpatient Facility Coding Alert - 2003 Issue 10
Reader Question: Include Chart Review in E/M
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Article Overview
This reader Q&A addresses chart review and record review in the context of evaluation and management (E/M) coding for physician office services. It explains the general treatment of reviewing older medical records as part of the visit work, discusses how summarizing records can affect medical decision-making, and notes how related data elements may influence selection of a higher-level E/M service. The article is aimed at coders and billers who need guidance on physician documentation, E/M leveling, and Medicare-related data considerations.
Why This Topic Matters
Reviewing records is a common part of patient encounters, and understanding how that work fits into E/M coding helps avoid unbundling errors and supports appropriate level selection.
What You Will Learn
- How record review is treated in the context of E/M services
- How summarizing chart information can relate to medical decision-making
- How related data elements may affect higher-level E/M service selection
- How Medicare-related points for history summarization are described in the article
Who Should Read This
- Medical coders
- Medical billers
- Physician office staff
- General surgery practices
Codes Discussed
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