Evaluation and management (E/M) codes represent the majority of the services reported by primary care pediatricians and many specialists.

The Centers for Medicare and Medicaid Services (CMS), state Medicaid programs, and most commercial payers rely on the 1995 or 1997 Documentation Guidelines for E/M Services as their requirements for reporting E/M services. Either set of guidelines may be used. Most pediatricians find the 1995 guidelines easier to follow, while some pediatric subspecialists may find the 1997 guidelines more applicable to their practices. Every physician should have a good understanding of the coding and documentation guidelines and a copy in the office. The guidelines can be accessed at http://www.cms.hhs.gov/MedlearnProducts/20_DocGuide.asp.

Even though they have been in existence for more than 10 years, the E/M guidelines continue to cause confusion because they are somewhat vague. For example, how does one differentiate between an expanded and detailed level of examination? If several coders,...

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