The New Face of Evaluation and Management: A Guide to Calculating E/M CPT Codes through Best Practice Documentation

Physicians want to care for patients, not spend their time documenting in an electronic medical record. Physicians are always complaining about the amount of time they spend documenting patient care in support of medical billing through an evaluation and management (E/M) coding system. New guidelines were created to lessen the time a physician/provider spends on documentation as many of the mandatory elements are no longer a requirement for calculating a code level. Previously an E/M (evaluation and management) note required documentation of history, exam and medical decision-making with required elements in each component to support a level for payment. If an element was missing, the level of service was not supported; therefore, the code was lowered, resulting in a lower reimbursement for the physician/provider. The new guidelines eliminated the requirement of history and exam as part of the calculation of a code level. Yes, an appropriate history and exam are required, this supports good patient care, but when it comes to reimbursement, they are no longer part of the picture.