Outpatient Facility Coding Alert - 2012 Issue 5
Reader Question: Skip HPI and Skip Your EM Pay
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Article Overview
This article addresses a documentation question from a surgical office encounter and discusses how incomplete history documentation affects evaluation and management reporting. It is aimed at coders, billers, and clinical documentation staff who support office/outpatient E/M claims and want to understand the documentation elements referenced in the guidance.
Why This Topic Matters
Incomplete documentation can affect whether an office/outpatient visit is reportable and what level of service may be supported. The article helps readers understand the general documentation expectations for E/M coding and why clear physician notes matter.
What You Will Learn
- Why history documentation matters in office/outpatient E/M reporting
- How missing documentation can affect new-patient encounters
- The distinction between new and established patient E/M documentation
- Why physician documentation habits matter for medical necessity support
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Physician documentation improvement staff
- Surgeons and office-based clinicians
Codes Discussed
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