ED Coding & Reimbursement Alert - 2013 Issue 5
Clip and Save: Keep This Chart Handy to Help Quickly Calculate Exam Levels
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Article Overview
This article is a quick-reference coding aid for professionals who assess evaluation and management physical examination levels. It focuses on the two guideline sets used for exam-level determination, the overall structure of exam component levels, and why coders may want a desk-side comparison tool when reviewing documentation.
Why This Topic Matters
Understanding the differences between the 1995 and 1997 exam guidelines helps coding staff review documentation more efficiently and support consistent evaluation and management level selection.
Article Sections
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Guideline overview
Introduces the purpose of comparing the two physical examination guideline sets and frames the article as a reference tool for coders. It also identifies the general context in which exam levels are reviewed.
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Levels of the Physical Exam Components
Begins the discussion of exam component levels and presents the structure used to compare physical examination findings across guideline approaches.
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Problem-Focused Exam
Starts the breakdown of specific physical examination levels within the chart-style reference. The section contributes to the broader comparison of exam scope and documentation depth.
What You Will Learn
- How the article frames comparison of physical examination guideline sets
- How exam component levels are organized in the reference chart
- Why a side-by-side exam level aid can be useful for coding review
- What general topic areas are addressed in the exam-level breakdown
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physician practice managers
- Evaluation and management documentation reviewers
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