Understanding E/M: Determine whether provider did expanded problem-focused or detailed exam

Why This Topic Matters

Determining the correct examination level is a common E/M coding challenge and can change the reported service level and reimbursement. The article helps readers understand the types of documentation review concepts and payer practices that can affect audit outcomes.

Article Sections

1. Overview of exam-level comparison under E/M documentation guidance

   Introduces the documentation issue and frames the comparison between two exam levels within Evaluation and Management review. It also references the relationship between the 1995 and 1997 guidance sets.

2. Coders’ rules of thumb

   Summarizes commonly used auditing approaches and how practitioners use exam scope concepts when reviewing documentation. The section discusses general methods used to assess exam complexity and specificity.

3. One carrier makes its own rules

   Describes a Medicare contractor’s local policy approach and how payer-specific guidance can affect exam review. It also notes discretionary review practices within that contractor’s framework.