Outpatient Facility Coding Alert - 2018 Issue 6
Reader Question: Know Your History for Successful E/M Chart Coding
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Article Overview
This short Q&A article covers the role of history elements in E/M chart coding and how current versus past patient information is categorized within documentation. It is aimed at coders and other documentation reviewers who need a quick refresher on history components, chart review concepts, and how documentation depth relates to E/M level selection at a high level.
Why This Topic Matters
Understanding how history elements are organized in E/M documentation helps coders and clinical staff read charts consistently and assess whether the record supports the level of service being considered.
What You Will Learn
- How current patient information is grouped within E/M history documentation
- How past patient information is grouped within E/M history documentation
- Why history documentation matters when evaluating E/M chart coding at a high level
- How a reader question format can clarify documentation concepts
Who Should Read This
- Medical coders
- Coding auditors
- Physician documentation staff
- Billers
- Compliance staff
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