Back to Basics: Can You Distinguish a Procedure From an E/M Service?

Why This Topic Matters

Accurate differentiation between procedures and E/M services affects compliant coding, audit risk, and the ability to support claims with documentation.

Article Sections

1. Review What Qualifies as E/M

   This section covers general same-day encounter scenarios and the broad documentation concepts used to determine whether E/M work is present alongside another service. It also references Medicare coding guidance and professional commentary.

2. Don’t Equate H&P With E/M

   This section explains the distinction between history and physical examination and broader E/M work, with discussion of documentation expectations. It also references Medicare coding guidance and the National Correct Coding Initiative.

3. Don’t Use E/M for Every New Patient Scenario

   This section addresses common assumptions about new patients, minor procedures, and preventive or nonsurgical encounters. It emphasizes documentation considerations and references E/M guideline updates.