In 2021, Evaluation and Management (E/M) code guidelines had a major overhaul. The American Medical Association (AMA) worked with the Centers for Medicare & Medicaid Services to update and simplify the requirements. History and exam elements no longer count towards the level of service allowing the treating physician to determine the extent of the history and physical examination.1 However, as with any office visit, a chief complaint is necessary to determine medical necessity.
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