General Surgery Coding Alert
Don’t Drop History and Exam
Question: With all the changes to E/M codes starting with office codes and now many other codes this year, I keep hearing that we no longer have to document history and exam. Is that true? Nebraska Subscriber Answer: No, it is not true that you no longer have to document history and exam for an evaluation and management (E/M) service. The revised guidelines state that the documentation should show that the provider performed a “medically appropriate” history and exam. If the history and exam is completely absent, that may open your practice up to trouble on audit. What changed: Under the new guidelines for the updated codes, the history and exam no longer counts directly toward the code level selection — that relies on the medical decision making (MDM) or time. However, you can find a lot of information in the history and exam that helps support the level of MDM, such as severity, status (chronic or acute), and stability of the condition. As a coder, you are going to be looking at the entire record to get a total picture. You won’t simply skip the history and exam elements in the medical record and move straight into MDM, because history and exam information is still important
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