decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Encounters dominated by counseling or coordination of care
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Article Overview
This article covers a short segment of the 1995 evaluation and management guidelines focused on encounters where counseling or coordination of care is the main factor in selecting service level. It is relevant to physicians, coders, and documentation staff who need to understand the general documentation expectations associated with time-based E/M selection in office, outpatient, hospital, or nursing facility settings.
Why This Topic Matters
Accurate documentation and understanding of time-based E/M selection affect compliance, claim support, and consistency in reporting encounter levels.
What You Will Learn
- How the guideline frames time when counseling or coordination of care dominates an encounter.
- What general documentation elements are expected when service level is selected using time.
- Which encounter settings the guidance broadly applies to.
- How this guidance relates to evaluation and management documentation.
Who Should Read This
- Physicians
- Medical coders
- Coding auditors
- Compliance staff
- Clinical documentation improvement specialists
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