decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 4 (April)
‘Complete' exam rule restricts E/M level surgeons can report
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Article Overview
This article discusses Medicare evaluation and management documentation guidance as it applies to general surgeons, especially the challenge of supporting higher-level visits, consultations, and admissions. It compares the two documentation frameworks Medicare uses for exam documentation and explains why the topic matters for surgeons, coders, and reimbursement staff reviewing history, exam, and medical decision-making requirements.
Why This Topic Matters
Understanding these documentation frameworks helps coding and compliance professionals assess whether a surgeon’s E/M documentation supports the reported service level under Medicare rules.
Article Sections
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The 1995 guidelines
This section summarizes the older Medicare documentation framework for multi-system examinations and the broad body systems it recognizes.
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The 1997 guidelines
This section reviews the later Medicare documentation framework for general multi-system examinations and how it organizes exam content across body systems and elements.
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Exception: Admission for surgery
This section addresses the circumstance in which a surgical admission may support more complete documentation under Medicare E/M guidance.
What You Will Learn
- How Medicare documentation guidance affects evaluation and management reporting for general surgeons
- How the 1995 and 1997 exam frameworks differ at a high level
- Why higher-level office, consultation, and admission services can be difficult to support in non-surgical situations
- What broad documentation components are involved in Medicare E/M level selection
Who Should Read This
- Medical coders
- Coding auditors
- General surgeons
- Compliance staff
- Practice managers
- Billing staff
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