Documentation and Coding Review: What the Record Must Support
Document what happened, code what is documented
The medical record must support the code on the claim. The classic formulation - if it was not documented, it was not done - decides most audit findings. Check authentication, date and time, author credentials, legibility, and whether amendments or late entries are properly identified.
E/M: know which rule set applies
Under the 1995/1997 guidelines, level is driven by history, examination, and medical decision making. Under the 2021+ office/outpatient guidelines, level is driven by medical decision making or total time on the date of the encounter. Do not mix frameworks. For MDM ask three questions: how many and how complex are the problems addressed; how much data was reviewed and analyzed; and what is the risk of complications, morbidity, or mortality? The highest two of the three set the level.
Diagnosis coding
Code to the highest specificity the record supports; follow sequencing and "code first / use additional code" notes; never infer laterality, diabetes type, or a causal linkage that is not documented. A medication list is not a diagnosis.
Querying
Queries must be non-leading, cite clinical indicators, and offer options consistent with the documentation. "Was this sepsis?" is leading. "Please clarify the significance of WBC 19.2 and lactate 3.1" is not.
Worked example
A 99214 is audited: problems addressed include two stable chronic illnesses (moderate), no data reviewed (minimal), and a prescription drug change (moderate risk). Two of three elements are moderate, so the level holds.
Traps
Cloned or copy-pasted notes, E/M leveled by the number of diagnoses, counting a review of systems never documented, and unattributed addenda.
Rule of thumb
Level the encounter by documented medical necessity, not by how many items appear on the problem list.