Outpatient Facility Coding Alert - 2013 Issue 1
Part B Revenue Booster: Get in the Habit of Taking A History That Won't Repeat Itself
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Article Overview
This article explains how physician documentation of patient history affects evaluation and management coding under Medicare Part B. It is aimed at coders, billers, and clinical staff who want to improve documentation quality, avoid downcoding, and understand general CMS guidance related to history-taking when a patient cannot provide information.
Why This Topic Matters
History documentation is a key component in E/M reporting, and missing or duplicated elements can affect whether a claim is supported at the intended level. The article focuses on broad documentation practices and a CMS exception relevant when history cannot be obtained.
Article Sections
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Five tips for documenting patient history
An overview of common documentation habits that can affect how patient history is captured for evaluation and management reporting. The section emphasizes general distinctions among documentation elements and recordkeeping practices.
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CMS guidance when history cannot be obtained
A discussion of the general Medicare exception described for situations where a patient cannot provide history. The section references CMS guidance and the type of circumstance that should be noted in the record.
What You Will Learn
- How patient history documentation fits into evaluation and management coding
- Why separating history from exam documentation matters
- Why complete documentation of patient responses is important
- How to avoid duplicating information across history components
- How CMS guidance addresses cases where history cannot be obtained
Who Should Read This
- Medical coders
- Medical billers
- Physician office staff
- Clinical documentation staff
- Healthcare compliance staff
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