Compliance: Check Documentation Before Deciding Which Set of E/M Guidelines To Use

Why This Topic Matters

Choosing the appropriate E/M examination guideline affects how visit documentation is interpreted during coding and audit review, making it important for accurate compliance and consistent physician documentation practices.

Article Sections

1. Focus on the 1995 vs. 1997 Differences

   Introduces the two E/M documentation guideline sets and explains that the examination component is the key area of difference. It also frames how the guidelines relate to office and outpatient evaluation and management services.

2. Choose the Best Guidelines Per Encounter

   Discusses using either guideline set on a per-encounter basis and notes that history and medical decision making are not changed by the choice. It also mentions payer and contract considerations.

3. Be Careful with Exam Templates

   Reviews the role of paper and electronic templates in exam documentation and emphasizes specialty tailoring. It also addresses the need for documentation to reflect the exam actually performed.