Coding, Chart Documentation and Reimbursement - Thurston ...

Documentation Improvement for Physician
Practices
Common E/M Service Documentation
Errors – Medical Decision Making
• MDM must address the chief complaint.
Additional conditions or concerns can be
address and may be more relevant but it is
important not to ignore the original reason for
the encounter.
• Free-floating diagnosis: Assessment:
Hypercholesterolemia, stable.
Not on problem list, not elsewhere in chart, no
labs referenced in note, no cholesterol
medicine.
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