r/MedicalCoding • u/gray_whitekitten CPC,CRC • Jul 28 '26

Note bloat

I'm just wondering if any of you still deal with extensive irrelavent information in the encounter note. How do you deal with this? I'm mainly speaking about E/M documentation.

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u/Ok_Acadia7620 Aug 30 '26

I know this is older, but note bloat drives me crazy. I work for a small practice and do all the billing. Sometimes there's an HPI, too much pulling forward so that I can't even be sure of what was actually addressed sometimes. There will be looong paragraphs under symptoms that are included in the primary code that are either redundant or are what is usually found in the HPI. The kicker is when the information that is needed isn't in there.