See why it’s vital to capture history and exam during E/M encounters

Article Overview

This Find-A-Code article is a general guidance piece for coding and documentation professionals who work with evaluation and management (E/M) services. It focuses on why history and exam documentation remain important even when they are not used alone to select the level of service, and it discusses how documentation supports medical decision-making, continuity of care, and payer methodologies that rely on clinical information. The article is relevant to coders, auditors, compliance staff, and clinicians who document E/M encounters.