Part B Insider - 2016 Issue 10
Reader Question: No Physical Exam? Established E/M Possible
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Article Overview
This short coding Q&A addresses documentation and code-selection considerations for office and other outpatient evaluation and management services in family medicine. It focuses on how established-patient and new-patient E/M documentation requirements differ, and notes the role of CMS documentation guidelines in interpreting recorded vitals and other encounter elements. The article is useful for coders working with outpatient physician documentation and E/M assignment.
Why This Topic Matters
Accurate E/M reporting depends on understanding which documentation elements are required for different patient categories. This article helps coders and clinicians align office visit records with outpatient E/M documentation expectations.
What You Will Learn
- How the article frames documentation requirements for established versus new patient office/outpatient E/M services.
- How the discussion relates to family medicine coding and outpatient encounter documentation.
- How CMS documentation guidelines are referenced in the context of exam-related documentation elements.
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Who Should Read This
- Medical coders
- Coding auditors
- Family medicine coding staff
- Physicians
- Practice managers
Codes Discussed
Code Ranges Discussed
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