E&M Documentation Arcana Revealed

 

Q. For purposes of documentation, what is the difference between an "expanded, problem-focused" examination and a "detailed" examination?

A. According to the 1995 Documentation Guidelines for Evaluation and Management Services the difference between these two types of examination is in the degree of detail documented about the body areas - not in number of body areas examined. Both examinations might include the same number of examined body areas.

Many medical practices lose money because of undercoding and poor documentation of their evaluation and management services.

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