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E m coding guidelines 2024 cheat sheet

E m coding cheat sheet 2021 pdf-2025

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The document outlines the E/M (Evaluation and Management) documentation assessment guidelines for Medicare patient encounters specifically under the TrailBlazer carrier in Texas, Virginia, Delaware, Maryland, and the District of Columbia. It details the categories of medical documentation audits: History, Exam, and Medical Decision Making (MDM), with a focus on how to determine the complexity of MDM based on diagnoses, management options, data reviewed or ordered, and risk levels. The document provides specific criteria for each category to ensure compliance with Medicare documentation standards.

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Click ‘Get Form’ to open the e m coding cheat sheet 2021 pdf in the editor.
Begin by entering patient details such as Patient Name, Facility, DOB, Encounter Date, and MRN in the designated fields at the top of the document.
Navigate to the 'E/M Documentation Assessment Using the TrailBlazer Method' section. Here, you will find categories for History, Exam, and Medical Decision Making. Fill out each component based on your encounter details.
For History, ensure you document the Chief Complaint and select relevant elements from HPI (History of Present Illness) and ROS (Review of Systems). Use checkboxes for chronic conditions as applicable.
In the Exam section, choose between Problem Focused or Comprehensive exams based on your assessment. Document findings clearly using bullet points.
Complete the Medical Decision Making section by evaluating Number of Diagnoses, Management Options, and Risk Levels. Ensure all points are accurately recorded to determine overall complexity.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

When should I use 99214?

Office or Other Outpatient Services Office or Other Outpatient Services office or other outpatient services: 99213 : Low : 20 minutes office or other outpatient services: 99214 : Moderate : 30 minutes office or other outpatient services: 99215 : High : 40 minutes office or other outpatient services:Prolonged Services8 more rows

What is the difference between EM code 99213 and 99214?

Based on Medical Decision Making◄ ►Four types of MDM are recognized: straightforward, low, moderate, and high.

Where can I find the full list of CPT codes?

3 Key Components of E/M Coding: History, Exam, Medical Decision Making. Note: This article is provided for historical reference.

When to use 99214 vs 99213?

A: Use 99213 for routine diabetes follow-ups with stable A1C and minimal medication changes (typically 20 minutes). Use 99214 for diabetes with complications, multiple medication adjustments, care coordination with specialists, or visits requiring 30+ minutes of comprehensive management.