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General Surgery Coding Alert

E/M Reporting:

Grab Value From '95 vs. '97 Guideline Distinction

Published on Wed Sep 12, 2012

Physical exam element can point you to the better set.You might boost your evaluation and management (E/M) code level -- or lose money for your surgeon's work -- depending on whether you follow the 1995 or 1997 E/M coding guidelines.If you've ever wondered which set is better for your general surgeon's encounters, focusing on how to tally the physical exam documentation can be your key to success.Choose More Systems or More ElementsThe key differences in the 1995 and 1997 guidelines involve how you "count" the physical exam.1995: Here's a breakdown of what you should document for each level of physical exam under the 1995 guidelines:Problem focused = 1 body system or area Expanded problem focused = 2-7 body systems or areas Detailed = 1 body system or area in greater detail and 1-6 brief system(s) Comprehensive = 8 or more body systems OR a complete single system exam. 1997: Contrast that to [...]
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