Use new E/M coding worksheet for level-based E/M encounters

Why This Topic Matters

E/M coding remains a major part of professional and facility billing, and tools that organize documentation review can help teams assess encounters consistently across settings. This article is relevant to anyone updating internal audit workflows or comparing older documentation-based scorecards with current E/M review practices.

Article Sections

1. Worksheet revision and scope

   Introduces the updated worksheet and the visit settings included in its scope. It also identifies the broad types of E/M encounters covered by the tool.

2. How the worksheet is used

   Describes the worksheet pages and the general purpose of each part of the tool. It outlines the broad approach to MDM-based review, time-based review, and final encounter documentation.

3. Reviewing documentation and audit notes

   Explains the role of chart review, coder/provider comments, and agreement with an assigned level. It also notes the continuing use of older scorecards for retrospective review and outside audits.

4. Resources

   Lists reference materials and source guidance cited by the article. This section points to the current CPT manual and a CMS manual chapter for additional context.