BC Advantage - 2023 Issue 1
The Role of the History and Examination in 2023 Evaluation and Management Services
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Article Overview
This article reviews the shift in Evaluation and Management guidance discussed in CMS and CPT materials, focusing on how history and examination are treated in the 2023 framework compared with prior documentation approaches. It is aimed at coders, auditors, compliance staff, educators, and other billing professionals who need to understand the broader implications of the revised E/M documentation environment and the terminology used by CMS and CPT.
Why This Topic Matters
The article helps readers interpret evolving E/M documentation expectations and understand why the history and examination elements continue to matter operationally even when they no longer drive code selection. It is relevant for organizations updating auditing, education, and compliance processes around the 2023 E/M framework.
What You Will Learn
- How CMS and CPT materials describe the updated E/M documentation framework
- Why the history and examination components remain important in 2023 discussions
- What questions the revised terminology raises for educators and auditors
- How the article frames the transition from older documentation approaches to the newer E/M structure
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Clinical documentation educators
- Physician practice administrators
- Revenue cycle staff
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