E/M Coding Alert - 2002 Issue 9
Reader Question: Comprehensive Exams
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Article Overview
This reader Q&A discusses the 1995 Evaluation and Management exam guidelines and explains the difference between documenting by organ systems versus body areas. It is aimed at coders, auditors, and clinicians who need a clearer understanding of comprehensive exam documentation for E/M reporting.
Why This Topic Matters
Accurate interpretation of exam structure affects E/M documentation review and consistency in medical record audit practices. The article helps readers understand the broad framework used in the 1995 guidelines without conflating two different ways of describing the physical exam.
What You Will Learn
- How the 1995 E/M exam guidelines describe comprehensive examinations
- The difference between organ-system documentation and body-area documentation
- Why organ systems and body areas should not be mixed in exam documentation
- How broad exam terminology is applied in a general coding context
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Clinicians
- Compliance staff
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