Medical record documentation is required to accurately record pertinent facts, findings, and observations in regards to a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and the evaluation and management documentation of a service is a key part of the medical record.
Evaluation and management (E&M) services provide the nature and amount of physician work, and documentation varies by type of service, place of service, and the patient's status. Providers must ensure that medical record documentation supports the level of service reported to all payers.
The ACR practice management team is offering a free one-hour Evaluation and Management Lunch & Learn webinar series to ensure compliance and accuracy with the new coding and documentation guidelines. The webinars are just the latest in a series of online resources developed to assist members and their staff prepare for the E&M coding updates. To register for the webinars, contact the ACR practice management team at email@example.com.
As of January 1, 2021, there were significant changes to the office and outpatient evaluation and management (E&M) services (CPT® codes 99202-99215) for both new and established patients.
View key E&M changes
On January 1, 2021, providers have the option to select the level of office and outpatient E&M services based on either MDM or time.
Learn more about E&M level selection
The American Medical Association (AMA) level of medical decision-making table.View revised medical decision-making table
Providers have the option to select the level of office and outpatient (E&M) services based on either time or MDM.Learn more about selection E&M level based on time
CPT created a new prolonged services code used to report total time, both with and without direct patient contact, after the time threshold for 99205 or 99215 is met.
View prolonged code decision tree
For step-by-step instructions on documenting and coding the correct level of the E&M services, download the following resources for rheumatology practices.
Rheumatology Coding Manual
E&M Coding Chart
E&M Documentation Example
CMS Evaluation and Management Service Guide