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Im Jane Blanchard with physician your company and today Ill do a deep dive into the finer points of documenting physical exams in your EM visits youve watched this video youll know how your notations about your physical exam affect your EM leveling EM documentation serves two very important functions first its the clinical record of your encounter its where you note why your patient is there to see you how they presented and what your plan is for helping them second it must also support your selection of the cpt and procedure codes you report to insurance carriers to be paid for your services there are two widely accepted versions of the guidelines which define how enm notes may support cpt selection and billing they are the 1995 version and the 1997 version in general the 1995 version is somewhat better aligned with pediatric primary care visits for this discussion will use those 1995 guidelines although the term enm describes services in all of the categories you see here t
