decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Amount and complexity of data to be reviewed
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Article Overview
This reference discusses the 1995 evaluation and management guideline criteria for the amount and complexity of data reviewed during an encounter. It is intended for clinicians, coders, and compliance staff who need to understand documentation expectations for diagnostic tests, outside records, additional history sources, and test-result review. The article focuses on general documentation guidance and examples of acceptable documentation language.
Why This Topic Matters
Accurate documentation of data review affects E/M level support and audit readiness. Understanding these guideline expectations helps organizations align note content with medical record review practices and diagnostic testing workflows.
What You Will Learn
- How the 1995 E/M guidelines frame data review
- What types of diagnostic information may affect documentation
- Which documentation elements should be captured in the medical record
- How review of outside records and additional history is documented
- What kinds of test-result review activities are addressed by the guideline
Who Should Read This
- Physicians
- Nurse practitioners
- Physician assistants
- Medical coders
- Clinical documentation specialists
- Compliance auditors
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