E/M Coding: Yes You Can Use Two Sets of E/M Guidelines

Why This Topic Matters

Selecting the appropriate E/M examination guideline can affect whether documentation supports the intended level of service and whether a claim aligns with the provider’s record and payer expectations.

Article Sections

1. Focus on the 1995 vs. 1997 Differences

   Introduces the two E/M physical examination guideline sets and describes the broad differences between them. It also situates these guidelines within office and outpatient visit coding for new and established patients.

2. Choose the Best Guidelines Per Encounter

   Explains that either guideline set may be used for a single encounter and that the choice can vary based on documentation and practice circumstances. It also notes that other E/M key components are unchanged.

3. Be Careful with Exam Templates

   Discusses the use of paper or electronic templates in exam documentation and cautions against inappropriate over-documentation. It emphasizes the role of medical necessity and specialty-specific tailoring.