Part B Coding Coach: 4 Q&A's End Your Exasperation With E/M Guidelines

Why This Topic Matters

Understanding how E/M documentation is interpreted can affect how encounters are coded and supported in the record. The article is especially relevant for practices that frequently document test orders, test review, and related medical decision-making.

Article Sections

1. Collect Credit for Diagnostic Decisions

   This section addresses how physician documentation around diagnostic choices is discussed in the context of E/M complexity and the care plan. It also includes a billing-oriented example involving patient refusal and test-related documentation.

2. Don't Dismiss HPI Elements

   This section focuses on history documentation and the handling of common HPI elements when symptoms are absent or not linked to certain triggers. It also references the broader role of documentation detail in establishing history level.

3. Award Credit for Test Ordering and Review

   This section covers CMS commentary on audit tools, test ordering, and review activity across different parts of CPT. It also notes specialty-specific relevance and the use of carrier audit tools.

4. Account for Image Ordering and Review Separately

   This section discusses separate documentation of ordering and personally reviewing diagnostic studies. It addresses how this activity is treated within the data portion of E/M complexity and the relevance for physicians who interpret their own studies.