decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix C - 1995 EM Guidelines / Number of diagnoses or management options
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Article Overview
This article covers a documentation-focused appendix from the 1995 evaluation and management guidelines. It explains how clinicians should reflect diagnostic assessment, problem status, treatment changes, and referral or consultation activity in the record. The material is useful for coders, auditors, compliance staff, and clinicians who need to understand the documentation expectations associated with medical decision making.
Why This Topic Matters
Accurate documentation of diagnoses, management options, and follow-up decisions is a core part of E/M coding review and audit readiness. This appendix helps readers understand the general documentation elements expected in the medical record.
What You Will Learn
- How the guideline frames the number of diagnoses and management options in documentation review
- What kinds of assessment or clinical impression documentation are expected
- How treatment changes and referral activity should be reflected in the record
- How problem status is generally documented for established diagnoses and for problems without an established diagnosis
Who Should Read This
- Medical coders
- Clinical documentation improvement specialists
- Compliance auditors
- Physicians and other billing providers
- Practice managers
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