Skip to content

The floor

What we see when the chart has to survive someone else opening it.

04

Primary careJune 18, 20264 min

E/M level is a decision. Template volume is not.

Clicking every box in the EHR does not raise the level. Medical decision-making has to be in the note, or time has to be stated. The rest is noise the auditor ignores.

By Priya Raman

Documentation specialist

Read
A primary-care visit underway in the exam room

05

DocumentationJune 2, 20265 min

AI can draft a note. It cannot close the chart.

A model will produce fluent sentences. It will not verify that billed units match the procedure note, or that a repeat application is justified under the LCD. That is the part an auditor reads.

By Elena Voss

Chart-review lead

Read
A hospital corridor after the visit — the chart still has to close