Part B Insider - 2002 Issue 4
Audit Worksheet Helps Coders Determine MDM Levels
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Article Overview
This article discusses emergency department evaluation and management coding, focusing on how coders assess documentation for history, physical examination, and medical decision-making. It describes the role of a commonly referenced audit worksheet, how practices may standardize their approach, and why the nature of the presenting problem can affect level selection. The piece is aimed at coding professionals who need to understand the general framework, documentation considerations, and audit support concepts involved in ED E/M coding.
Why This Topic Matters
Accurate ED E/M level selection depends on consistent interpretation of documentation and supporting tools. Understanding the general audit approach and documentation factors helps coders and compliance staff apply internal standards more consistently.
Article Sections
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Two Approaches Ease MDM
This section discusses general approaches for standardizing evaluation and management decision-making review in emergency department settings. It also introduces a commonly used audit worksheet and its role in supporting practice guidelines.
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In ED, NOPP Outweighs Key Components
This section addresses how the presenting problem can influence service level selection in emergency department coding. It describes the relationship between clinical urgency and the usual documentation components reviewed for E/M services.
What You Will Learn
- How emergency department coders review documentation for evaluation and management services
- Why medical decision-making is often the most subjective component of ED E/M coding
- How an audit worksheet can support internal documentation review processes
- How practices may standardize evaluation and management decision-making standards
- How the nature of the presenting problem can affect ED service level selection
Who Should Read This
- Emergency department coders
- Coding auditors
- Compliance staff
- Health information management professionals
- Physician practice coding staff
Codes Discussed
Code Ranges Discussed
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