decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Appendix A_EM Guidelines / 1995 EM Guidelines / Overview
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Article Overview
This article summarizes the 1995 E&M documentation guidelines and explains the general framework used across multiple service settings. It is aimed at coders, auditors, and clinical documentation staff who need to understand the scope of the guidelines, the principal components used in level selection, and the types of patient-specific documentation variations the guidelines recognize.
Why This Topic Matters
The 1995 guidelines are foundational for E&M documentation review, so understanding their structure helps readers evaluate whether records support the intended level of service across common care settings.
What You Will Learn
- The overall structure of the 1995 E&M documentation guidelines
- The major components used in evaluating E&M services
- How documentation emphasis can differ for counseling- or coordination-focused visits
- Why documentation may vary for certain patient groups
- What kinds of general patient population variations are recognized in the overview
Who Should Read This
- Medical coders
- Compliance auditors
- Clinical documentation improvement staff
- Physician office staff
- Billing professionals
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