This page addresses follow-up questions and additional information pertinent to our webinar
Documentation Decoded: E/M Insights From Coders to Clinicians.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q:  I get that real charts are ideal, but what about HIPAA rules?​

A:  Good point! If you can use real charts, take the time to carefully remove any patient identifying information. Many times, patient information is in multiple spots within record. Look through the actual note and headers/footers to make sure all is removed. You may also want to have a peer take look to make sure you didn’t miss anything. Remove: Name, MRN# (or any other specific patient account numbers), and any other items that could be used to identify the patient. If sending the information via email, take care to NOT send a version where the redactions can be removed to visualize patient identifiers.​

Q:  What if I don’t know the answer to a question that a provider asks during a session?​

A:  Don’t fret! Tell the provider that you will research the question and provide an answer back. Make sure and have a way to contact the provider with the correct answer (e.g., through the clinic administrator or directly to the provider’s email). It’s best not to guess, to avoid future confusion.​

Q:  What’s the best way to send handouts?​

A:  We recommend sending the handouts via email in a PDF format, prior to your scheduled meeting time. This way, the provider will have them for reference, and they are not editable. Remember to redact any PHI before sending.​