Part B Insider - 2021 Issue 6
Reader Questions: Live By The Physician’s Documentation
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Article Overview
This brief reader-question article discusses how coding decisions depend on what is documented in the physician record. It is aimed at coders and billing staff who need to determine whether documentation supports an evaluation and management service, a procedure service, or both on the same date of service.
Why This Topic Matters
The article reinforces the importance of documentation review before selecting a code. It is relevant to anyone handling office and procedure-based claims where E/M services may be considered in addition to a procedural service.
What You Will Learn
- How to think about coding questions in relation to physician documentation
- The general factors that determine whether documentation supports an E/M service
- How same-day procedural and E/M services are discussed at a high level
- Why documentation review is central to code selection
Who Should Read This
- Medical coders
- Billing staff
- Practice managers
- Compliance staff
Codes Discussed
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