Medicare Compliance & Reimbursement - 2020 Issue 7
Reader Questions: Will History, Exam Stay or Go in 2021? The Answer May Surprise You.
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Article Overview
This article explains a subscriber question about the 2021 changes to office and outpatient evaluation and management documentation under CPT®. It focuses on the role of history and examination in clinical documentation, how those elements relate to medical decision making, and why coders still review the full record even when those elements are no longer used to select the service level. The piece is aimed at coding professionals and practices working with office-based and outpatient E/M services.
Why This Topic Matters
It helps readers understand a widely discussed E/M documentation change and avoid confusing documentation requirements with level-selection criteria.
What You Will Learn
- How the 2021 office and outpatient E/M framework affects documentation review
- Why history and examination remain clinically important in patient encounters
- How coders consider the entire record when supporting medical decision making
- How revised CPT® office/outpatient descriptors are described in the article
Who Should Read This
- Medical coders
- Coding auditors
- Physician practices
- Pulmonology practices
- Outpatient E/M documentation staff
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