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This coding guide will describe the guidelines for evaluation and management (E/M) services reported in the office or outpatient department, consultations, ED visits, inpatient and observation hospital visits, nursing facility and home services. There are specific changes related to these categories of codes described here. The guide will also discuss how to select the level of service based on either time or medical decision-making.
Not included in the guide are the rules for critical care, preventive medicine services, and prolonged visits. Medicare’s split/ shared services are also not covered in this guide. All of those topics have their own articles, guides and in some cases videos here on CodingIntel. You can find those in the site table of contents.
Table of contents
- History and exam
- Split/shared services
- Using time
- E/M and procedure of the same date of service
- First element of MDM
- Second element of MDM
- Third element of MDM
- Guideline overview
- Types of services
- Reference sheets: E/M services
- Reference sheet: typical time
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