decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Documentation of examination
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Article Overview
This article explains the 1995 E/M examination framework and the documentation expectations tied to it. It is useful for coders, auditors, clinicians, and compliance staff who need to understand how examination findings are structured and recorded across body areas and organ systems. The article also summarizes general documentation guidance for normal, abnormal, and relevant negative findings.
Why This Topic Matters
Examination documentation is a core component of E/M code selection and audit support. Understanding the 1995 guidelines helps teams evaluate whether records are complete, appropriately organized, and aligned with the documentation standards referenced in the article.
Article Sections
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Types of examination
Summarizes the main categories used to classify examination scope within the 1995 E/M framework.
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Body areas recognized for examination
Lists the broad body areas identified for exam documentation purposes.
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Organ systems recognized for examination
Lists the organ systems used when documenting examination findings.
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Extent of examinations and documentation guidelines
Describes general expectations for recording examination findings, including normal, abnormal, and relevant negative observations.
What You Will Learn
- How the 1995 E/M examination types are organized
- Which body areas are recognized for exam documentation
- Which organ systems are recognized for exam documentation
- What general documentation expectations apply to examination findings
- How exam extent is described in relation to the presenting problem
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians and other clinicians
- Revenue cycle staff
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