BC Advantage - 2024 Issue 2

The Stability Factor: Documenting Chronic Exacerbated Conditions

I have been in the healthcare field for more than 35 years, and remember when we didn't have Evaluation and Management (E/M) codes. Then, we went through the 1995 and 1997 guidelines from CMS. All the elements, boxes, borders – UGH! Now, we have a cleaner way to document E/M services with the 2021 and 2023 updates.   At first, I heard comments on how easy the new guidelines are and how physicians/APPs would make the transition seamless. Well, we are a couple of years in now, and I continue to see issues when I audit records documenting a...

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