Outpatient Facility Coding Alert - 2004 Issue 10
Reader Questions: Say No to 'Past History Negative'
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Article Overview
This short article addresses a documentation question related to evaluation and management history elements. It explains the general issue of how a vague charted phrase may be interpreted by auditors and why physicians should document a specific history element for the relevant history component. The piece is aimed at coders, auditors, and clinical documentation staff who review E/M records.
Why This Topic Matters
Clear history documentation affects how evaluation and management services are supported in the medical record and how auditors may view the note. The article helps readers understand why precise documentation matters for compliant chart review.
What You Will Learn
- How a vague history statement may be viewed in E/M documentation
- Why specific documentation elements matter in the history portion of a note
- How auditors may interpret nonspecific past history wording
- The importance of documenting a concrete history element for review
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation specialists
- Physicians and other clinicians
- Compliance staff
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