decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix A_EM Guidelines / 1995 EM Guidelines / B. Documentation of Examination
Subscribe or sign in to view the full article.
Article Overview
This reference page covers the 1995 E&M examination documentation guidelines. It outlines the main examination categories, the body areas and organ systems recognized for documentation, and the general expectations for recording findings in the medical record. It is useful for clinicians, coders, and auditors who need to understand how examination documentation is organized under the 1995 guideline structure.
Why This Topic Matters
Understanding this guideline helps ensure examination documentation is complete and structured in a way that supports evaluation and management reporting review. It is relevant for anyone assessing whether a record reflects the appropriate breadth and level of examination under the 1995 framework.
Article Sections
-
Examination Types
Introduces the broad categories used to classify examination extent within the 1995 E&M framework.
-
Body Areas Recognized for Examination
Lists the body areas referenced for documenting examination findings.
-
Organ Systems Recognized for Examination
Lists the organ systems referenced for documenting examination findings.
-
Documentation Guidelines
Summarizes general expectations for recording examination findings in the medical record.
What You Will Learn
- How the 1995 E&M examination framework organizes examination extent
- Which body areas are recognized for examination documentation
- Which organ systems are recognized for examination documentation
- What general documentation expectations apply to examination findings
Who Should Read This
- Medical coders
- Clinical documentation specialists
- Auditors
- Physicians and other clinicians
- Revenue cycle staff
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com