E/M 2021: History and physical exam still count for office visits 99202-99215

Why This Topic Matters

The article addresses a major shift in office visit documentation that affects how clinicians document encounters and how coders evaluate records for support. It matters to practices trying to align documentation with current office E/M policies while maintaining continuity of care and claim support.

Article Sections

1. Changes created confusion

   This section discusses why the updated office visit documentation approach prompted questions and uncertainty. It references the broader effort to reduce documentation burden and highlights commentary from medical directors at a national symposium.

2. Ground rules for documentation

   This section outlines the general expectations for documenting history and examination under the updated office visit framework. It summarizes guidance from Medicare contractors and notes how documentation should align with the patient’s presentation and medical necessity.