decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Documenting complexity of medical decision making
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Article Overview
This article is a reference on the 1995 E/M guidelines for documenting the complexity of medical decision making. It is useful for coders, auditors, and clinical documentation staff who need to understand the general structure used to distinguish levels of E/M service complexity and the documentation elements considered.
Why This Topic Matters
Clear documentation of medical decision making supports accurate E/M level selection and consistent review of encounter complexity. This material helps readers understand the general framework used in documentation and auditing workflows.
What You Will Learn
- How the 1995 E/M guidelines characterize medical decision making
- The main documentation elements used to assess complexity
- How decision-making levels are organized conceptually across increasing complexity
- How the article presents the relationship between documentation and E/M service level selection
Who Should Read This
- Medical coders
- Medical auditors
- Compliance staff
- Physician documentation improvement staff
- Clinicians documenting E/M services
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