Codes and Documentation for Evaluation and Management …

294 Codes and Documentation for Evaluation and Management ServicesThe Evaluation and Management (E/M) Codes were introduced in the 1992 up-date to the fourth edition of Physicians Current Procedural Terminology (CPT).These Codes cover a broad range of services for patients in both inpatient andoutpatient settings. In 1995 and again in 1997, the Health Care Financing Ad-ministration (now the Centers for Medicare and Medicaid Services, or CMS)published Documentation guidelines to support the selection of appropriateE/M Codes for services provided to Medicare beneficiaries. The major differ-ence between the two sets of guidelines is that the 1997 set includes a single-sys-tem psychiatry examination (mental status examination) that can be fullysubstituted for the comprehensive, multisystem physical examination requiredby the 1995 guideline. Because of this, it clearly makes the most sense formental health practitioners to use the 1997 guidelines (see Appendix E).

30 Procedure Coding Handbook for Psychiatrists, Fourth Edition to use one set of codes over another should be based on which code most accu- ... and established patients in the emergency department. The other terms used in the E/M descriptors are equally as important.

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