History and exam for E/M services
- CPT® revised the definitions of and documentation requirements for new and established patients starting in 2021, and extended the framework to other E/M services in 2023.
Clinicians have long objected to the bullet counting and systems listing required for high-level E/M services. Sometimes, missing only family history for an 85-year-old patient would cause the visit to be coded at a low level, no matter how complex the patient was. With the addition of electronic health records, everyone agreed that there was often unnecessary and repetitive information in the record, and at times the information was contradictory or unbelievable. Many clinicians thought that complexity should guide code selection. Now, for all E/M services, neither history nor exam are key components in code selection.
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