Check your coding against these answers to see where you should focus your E/M education. Answer 1: Both the 1995 and 1997 E/M documentation guidelines include the following: "A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: Answer 2: The answer depends on your practice, your urologist, the documentation, and the encounter specifics. You can choose whichever set of guidelines is most advantageous for each encounter, explains Suzan Berman, CPC, CEMC, CEDC, Senior Director of Physician Services at Healthcare Revenue Assurance Associates based out of Plantation, Florida. The key, however, is that you have to use either 1995 or 1997 guidelines for a single encounter. "Typically the 1995 documentation guidelines are going to be more advantageous for most practices," says Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, audit manager for CHAN Healthcare in Vancouver, Wash. "This is because they are more flexible and also because they reflect the way most physicians were taught to document. However, some physicians may have been taught or may have developed good documentation practices around the 1997 guidelines, and this may be advantageous to them." Answer 3: This mindset is particularly worrisome with the implementation of EHR systems, which often automatically code encounters without regard to medical necessity. It is very easy to document high levels of history and exams, particularly for established patients, which will result in level four and five services when the medical necessity may dictate only level two or three services. Caution: