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Exam | Documentation Guidelines for E/M Services

This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202–99215 in 2021. Continue to use the 1995/1997 guidelines for E/M services, except for codes 99202–99215. 

Definition

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.

Explanation

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.

Codes

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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Last revised August 18, 2021 - Betsy Nicoletti
Tags: level of service_Exam

Wondering about the rules for HCC coding?

Wondering what the rules are for HCC coding, and where you can find them? This video answers your questions. The topic is important to medical practices because risk-adjusted diagnosis coding is part of Medicare Advantage contracts, many commercial contracts and Accountable Care Organizations (ACOs). Sign up for our monthly newsletter to download the whitepaper and watch the video.

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Our mission is to provide accurate, comprehensive, up-to-date coding information, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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