E/M coding: A new era warrants new documentation guidelines

Why This Topic Matters

It highlights documentation language that may be outdated in electronic records and explains why evolving E/M documentation expectations matter to coding accuracy and compliance.

Article Sections

1. Overview of the CPT Symposium discussion

   Introduces the session that prompted the discussion and frames the broader documentation issues raised for E/M services.

2. Current CMS E/M documentation guidelines

   Summarizes the two currently used documentation guideline versions and compares their general focus areas.

3. Outdated guideline language in the electronic health record era

   Reviews examples of guideline wording that may not align well with electronic documentation workflows and modern recordkeeping practices.

4. Medical decision making as a key component

   Discusses how medical decision making is treated within E/M reporting and why it remains a point of concern for some organizations.

5. Impact on established patient office visits and subsequent hospital care

   Covers the E/M categories referenced in the discussion and the documentation concepts associated with those service groups.

6. Looking ahead

   Notes that additional issues and possible CMS changes are expected to be addressed in a follow-up article.