I hope you’re sitting down, because there is big news! The proposed physician fee schedule rule was released in mid July and includes a section about E/M (evaluation and management services). CMS is asking for comments about changing the documentation guidelines! The current guidelines were developed in 1995 and 1997, prior to the adoption of […]
Archives for July 2017
Reporting Excision of Multiple Lesions of the Same Size
Question: The doctor I work with excised two benign lesions from a patient’s arm, of the same length.  Do I add them together and report one code? Each was .5 cm.  Do I report 11400 twice or 11401 once? Answer: Report 11400 twice. Laceration repairs of the same depth and location are added together, but […]
History | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023. This article does not apply to services performed after 1-1-2023. Definition History is one of the three key components (history, exam, and medical decision making) of Evaluation and Management Services. […]