Ordered, Reviewed, or Just Listed? What Really Counts as E/M Data

A note may contain a long list of lab tests, imaging studies, and outside records. But which of those items actually count toward the data element of E/M medical decision making? In this episode of Auditing Antics, Stephanie and Michele break down the questions that come up when auditing E/M data. They discuss the difference between an order, a result review, and information that is simply carried into the note. They also explore why ordering and later reviewing the same test does not automatically give you two data points, and why the number of items in a chart does not tell the whole story. If you code, audit, or document E/M services, this episode will help you take a closer look at what the clinician did with the data and what the record supports. #AuditingAntics #MedicalCoding #EMCoding #EvaluationAndManagement #MedicalDecisionMaking #EMData #CodingCompliance #MedicalAuditing #ClinicalDocumentation #HealthcareCompliance #CodingEducation #PhysicianDocumentation #RevenueCycle