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BC Advantage - 2024 Issue 2
The Stability Factor: Documenting Chronic Exacerbated Conditions
I have been in the healthcare field for more than 35 years, and I remember when we didn't have Evaluation and Management (E/M) codes. Then, we went through the 1995 and 1997 guidelines from CMS. All the elements, boxes, borders – ugh! Now, we have a cleaner way to document E/M services with the 2021 and 2023 updates. At first, I heard comments on how easy the new guidelines are and how physicians/APPs would make the transition seamless. Well, we are a couple of years in now, and I continue to see issues when I audit records documenting...
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