E/M Coding: Get These 5 E/M Answers--Straight From the Source

Why This Topic Matters

E/M coding often turns on documentation and operational details that are easy to misinterpret. This article helps readers understand the scope of current CMS and contractor guidance before they review the full premium discussion.

Article Sections

1. DNR Discussions May Not Impact Level

   Discusses CMS contractor guidance on how a conversation documented in the record may affect evaluation and management level assessment. The section frames the question around risk-related documentation and overall visit evaluation.

2. You Certainly Can Bill Incident to for NPs

   Summarizes Medicare guidance on incident-to services and the types of practitioners and supervision considerations involved. The section also touches on documentation expectations tied to physician involvement.

3. Classify New Vs. Established Patients

   Explains CMS guidance on how new and established patient status is determined for Medicare E/M purposes. The section also references specialty considerations and related claims-processing references.

4. Avoid Sending Documentation Without Request

   Covers contractor guidance on when supporting documentation should be submitted for review. The section addresses the handling of records in relation to requests and related administrative processes.

5. Tally Your MDM Points Accurately

   Reviews guidance on medical decision-making point assignment for diagnostic test ordering and review activities. The section also notes how certain review actions are treated within the broader E/M framework.