The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.
This article does not apply to services performed after 1-1-2023.
Exam is one of the three key components (history, exam and medical decision making) of Evaluation and Management Services. Read about history here and medical decision making here.
E/M codes are defined by the level of key components performed and documented.
A significant difference between the 1995 and the 1997 guidelines is in the exam area. The 1995 exam guidelines are less specific and more open to auditor interpretation than the 1997 guidelines. In the 1997 guidelines, there are also single specialty exams that are useful to some clinicians, particularly Psych, ENT and Eye.
Used to describe the E/M codes in the medicine section of the CPT® book.
Billing and Coding Rules for Documenting Exam
The 1995 exam is divided into body areas and organ systems. For a comprehensive exam, 8 organ systems (not body areas) are required:
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