Part B Insider - 2022 Issue 6
Reader Questions: Stick to Documentation When Reporting Encounters Related to COVID-19
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Article Overview
This article addresses documentation-focused guidance for reporting emergency department evaluation and management services in encounters involving COVID-19 and multiple comorbidities. It is aimed at coders and billing staff who need to understand how provider documentation affects service level selection, when chronic conditions may be relevant to the current visit, and why clarification may be needed when notes are incomplete.
Why This Topic Matters
Accurate E/M reporting depends on the record rather than assumptions drawn from a patient’s broader history. This guidance helps reduce unsupported code selection and encourages documentation review and clarification when comorbidities may affect encounter complexity.
What You Will Learn
- How documentation supports ED E/M level selection for COVID-19 encounters
- Why comorbidities may or may not affect reported service level
- When chronic conditions can be considered relevant to the current visit
- Why clarification is appropriate when provider notes are unclear
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Emergency department coding professionals
Codes Discussed
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