decisionhealth Newsletters, Answer Books - 2009 Issue 2 (February)
Evaluation and Management Services / Selecting a level of EM service
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Article Overview
This article explains how to approach evaluation and management (E/M) level selection in a general coding context. It outlines the major documentation elements used to support E/M levels, compares how key components are applied across common encounter types, and points readers to separate documentation guideline references for more detailed instruction. The content is most relevant to coders, billers, auditors, and clinicians who document E/M services.
Why This Topic Matters
E/M level selection affects coding accuracy and documentation compliance. Understanding the broad structure of the decision process helps reduce undercoding, overcoding, and documentation errors.
Article Sections
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Selecting the level of E/M service
Introduces the overall process for determining the level of an E/M service and the main factors used in that determination.
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History, examination, and medical decision making
Summarizes the three major components used in E/M level assessment and describes the broad levels applied to each component.
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Category- and subcategory-specific requirements
Lists common encounter types and notes how key components are applied across different E/M categories and subcategories.
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Time as the controlling factor
Explains when counseling or coordination of care may make time the primary factor in level selection.
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Related documentation guidelines
Directs readers to separate year-specific E/M documentation guideline resources for more detailed guidance.
What You Will Learn
- How E/M service levels are generally evaluated
- Which major documentation elements are considered in level selection
- How encounter categories differ in their component requirements
- When time may become the controlling factor for E/M coding
- Where to look for more detailed E/M documentation guidance
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Clinical documentation staff
- Physicians and other qualified health professionals
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