Which documentation issue is classified as an E/M coding error related to authorship?

Which documentation issue is classified as an E/M coding error related to authorship?

• A. Documentation is legible
• B. Documentation is initialed or signed
• C. Documentation is not initialed or signed
• D. Documentation is complete and signed

Answer: (C)

Authorship authentication is essential in E/M documentation. Each note must be attributed to a clinician by initials or signature so that readers—and coders—know who authored it. When a record is not initialed or signed, there’s no clear author, which creates an authorship error that can affect coding and accountability. Legibility affects readability but not who authored the note, and a complete, signed document is proper documentation, not an error.

Authorship authentication is essential in E/M documentation. Each note must be attributed to a clinician by initials or signature so that readers—and coders—know who authored it. When a record is not initialed or signed, there’s no clear author, which creates an authorship error that can affect coding and accountability.

Legibility affects readability but not who authored the note, and a complete, signed document is proper documentation, not an error.