Outpatient Facility Coding Alert - 2015 Issue 24
Reader Questions: Confront Potential Coding Discrepancies
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Article Overview
This article addresses a coding review question from emergency medicine involving a possible discrepancy between the documented level of service and the medical record. It explains the need to compare the chart with the physician’s documentation, review critical care guidance, and consider how broader evaluation and management documentation principles apply. The piece is aimed at coders and compliance staff who need to evaluate physician-reported service levels without overstepping the record.
Why This Topic Matters
Understanding how to resolve documentation and service-level discrepancies helps coders support accurate billing, reduce compliance risk, and apply critical care and emergency department guidance consistently.
What You Will Learn
- How to approach a suspected discrepancy between documented care and the medical record
- Why review of critical care guidance matters in emergency department coding
- What general documentation factors should be checked before finalizing the service level
- How evaluation and management coding review can support compliant reporting
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Emergency department billing staff
Codes Discussed
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