CodingIntel

Medical coding resources for physicians and their staff. CodingIntel was founded by consultant and coding expert Betsy Nicoletti.

E/M Services – History and Exam

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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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- Betsy Nicoletti
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CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

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.