Document every condition you address
For each condition managed at the visit, record its status and your plan, for example stable, improving or worsening, and the action taken. Conditions listed without assessment usually can't be coded for that encounter.
Be specific
- Laterality (left, right, bilateral)
- Type and severity, such as acute vs. chronic or controlled vs. uncontrolled
- Linked complications, for example diabetes with neuropathy
- Episode of care for injuries
Support the E/M level
When coding by medical decision making, document the problems addressed, data reviewed and the risk of management. When coding by time, record the total time you personally spent on the date of the encounter.
Use templates carefully
Copy-forward and templates save time but can carry outdated or contradictory information. Update each note to reflect the current visit.
Frequently Asked Questions
Does a longer note mean a higher E/M level?
No. The level is based on medical decision making or time, not note length.