Current guidelines for office evaluation and management (E/M) services do not include levels of history and examination in the determination of the level of service provided (ie, code selection). This does not mean that documentation of history and examination are not required or not relevant to code selection. It does mean that documentation can be limited to information that has clinical significance without affecting code selection (ie, documenting clinically insignificant history and examination findings doesn’t raise the level of service).
From a code selection and compliance standpoint, documentation of the positive and pertinent negative findings of the patient’s history obtained and examination performed are significant to supporting the level of medical decision-making of the encounter. It is also essential to document who provides the history when the patient cannot fully provide it, as this increases the amount and/or complexity of data to be reviewed and analyzed. Documentation of the extent...
