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Exam | Documentation Guidelines for E/M Services

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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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- Betsy Nicoletti
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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

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.