Part B Insider - 2014 Issue 8
Reader Question: Code to Reflect the Extent of the Physician Discussion
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Article Overview
This reader question addresses how documentation gathered on an electronic pad factors into evaluation and management history reporting. It is aimed at coders, billers, auditors, and physicians who need to understand which parts of the history may be counted when information is reviewed and incorporated into the encounter note. The article focuses on documentation roles, guideline-based history elements, and how physician note content affects whether the history level can be supported.
Why This Topic Matters
History leveling affects evaluation and management code selection, documentation compliance, and audit defensibility. Understanding how patient-supplied information, ancillary documentation, and physician verification interact helps reduce coding risk and supports more accurate encounter documentation.
What You Will Learn
- How patient-entered information may relate to history documentation
- Which history elements require physician confirmation in the note
- How ancillary or patient-documented information can be incorporated into the encounter record
- How physician review and subsequent documentation affect history leveling
- How the 1995 and 1997 E/M guidelines are referenced in documentation review
Who Should Read This
- Medical coders
- Medical billers
- Compliance auditors
- Physicians
- Practice managers
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