AE Articles
Evaluation and Management (E/M) Office Visit Refresher
May 2024
Issue: May/June 2024
File Type: PDF
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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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About the Author
Brittney Irwin, COT, CPC, CEP
is a consultant for the Billing, Coding, and Compliance Division (BCCD) of BSM Consulting (800-832-060; CodingandCompliance@bsmconsulting.com)

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