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Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
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The “amount and complexity of the data reviewed” are
quantified by referring to the following table: |
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The physician should be aware that no “double dipping” is allowed. For example, if you review lab results and order labs during the same visit, you only get one point (not one point for ordering and one point for reviewing). This same rules applies to imaging studies or other medicine tests such as EKGs or PFTs. Commonly overlooked points are those garnered for obtaining or reviewing old records. If you do review old records, you must summarize your findings in the chart. It is not acceptable to just say, “Old records were reviewed.”
E/M University Coding Tip: Notice that points can accumulate quickly if you personally review an image, tracing or specimen. You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician (as when a radiologist provides an official interpretation for an X-ray). However, you must include your own interpretation in the chart in order to claim these points. |
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