Special Report: Side by side comparisons of E/M guidelines

Why This Topic Matters

E/M coding depends heavily on documentation standards, so side-by-side comparisons help readers understand how different guideline sets align and where the documentation framework is structured differently. This supports more consistent audit review, training, and documentation practices without needing to interpret the full premium report.

Article Sections

1. Comparison of 1995/1997 E/M documentation guidelines vs. HCFA's June 2000 draft guidelines

   Introduces the side-by-side comparison and frames the article as a review of how several E/M guideline versions are organized. It sets up the major documentation elements discussed throughout the report.

2. HISTORY

   Reviews the history component across the compared guideline sets. The section addresses the broad structure of history documentation and how the frameworks classify its elements.

3. REVIEW OF SYSTEMS (ROS)

   Summarizes the review-of-systems framework in each guideline version. It compares how the different approaches group and count systems for documentation purposes.

4. PAST/FAMILY/SOCIAL HISTORY (PFSH)

   Compares the past, family, and social history component across the guideline versions. It outlines how the documentation structure varies by service category.

5. ELEMENTS (HPI, ROS, PFSH)

   Presents the overall relationship among the major history elements. The section explains the broad framework used to qualify different history levels.

6. 4 Types of History and Criteria

   Organizes the history framework into the major history types and compares the criteria structure across the guideline sets. It provides a high-level view of how history is categorized.

7. Physical Examination Types

   Compares the main physical examination categories used in the guideline versions. The section focuses on how exam types are grouped and described.

8. LEVELS

   Presents the exam levels and how they are organized in the compared frameworks. It highlights the overall structure of examination documentation levels.

9. Criteria for 4 Types of Physical Examination

   Compares the criteria structure for the four physical examination types across the guideline sets. The section summarizes the documentation framework at a broad level.

10. Medical Decision-Making

    Reviews the medical decision-making component and how complexity is categorized in each guideline version. It focuses on the structure of decision-making assessment.

11. Counseling and/or Coordination of Care

    Summarizes guidance related to counseling and care coordination as it relates to time and documentation. The section compares how the guideline versions treat this service component.