AAPC - Back to school
Results 1 to 2 of 2

Thread: E/M Documentation Requirements

  1. #1
    Join Date
    Apr 2007

    Exclamation E/M Documentation Requirements

    AAPC: Back to School
    I'm needing some help. I have a doc in our office that keeps using the words, "there is no change in HPI or PE, please refer to previous dictations. I have found documentation showing that if nothing has changed in the ROS or PFSH that you can document nothing has changed and the date. Is there anywhere that states what can and cannont be documented in the pt's dictation for the HPI and PE.? I feel that if he is using that sentence then it's going to look like like he's duplicating the service from the prior visit. I just need to find the documentation to support whether it can or can't be done.

  2. #2
    Join Date
    Apr 2007
    Central Pittsburgh


    I know I actually have a site where it is illustrated, however, I've been searching and haven't yet found it.

    However, in the meantime, the Documentation Guidelines do a lot in this regard. They mention when things CAN be referenced. And my NOT mentioning when things CANNOT be referenced, one should understand that to mean that it cannot be referenced. I cut the below passage out of the DG for 1995. It was clearly stated in the history section and purposefully not in the exam section as it does not pertain.

    A ROS and/or a PFSH obtained during an earlier encounter does not need to
    be re-recorded if there is evidence that the physician reviewed and updated
    the previous information. This may occur when a physician updates his or
    her own record or in an institutional setting or group practice where many
    physicians use a common record. The review and update may be documented
    • describing any new ROS and/or PFSH information or noting there
    has been no change in the information; and
    • noting the date and location of the earlier ROS and/or PFSH.

    I hope this helps to some degree.

    Suzan Berman CPC, CEMC, CEDC

Similar Threads

  1. Documentation requirements
    By m.matos@chcfl.com in forum Auditing General Discussion
    Replies: 2
    Last Post: 02-02-2015, 12:30 PM
  2. documentation requirements
    By chadandleanne@windstream.net in forum Emergency Department
    Replies: 0
    Last Post: 02-27-2014, 11:28 AM
  3. Documentation requirements
    By mcohen in forum OB/GYN
    Replies: 0
    Last Post: 06-04-2013, 10:24 AM
  4. Documentation Requirements
    By rizeninme in forum Compliance General Discussion
    Replies: 1
    Last Post: 12-30-2010, 03:58 PM
  5. Documentation requirements
    By TY0411 in forum Medical Coding General Discussion
    Replies: 2
    Last Post: 11-18-2010, 06:28 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.