Emergency Medicine 
   Documentation Review
       2020
      Documentation Provides
      • Proof of the delivery of quality patient care
      • Better protection medico-legally
      • Ability to ensure accurate billing and reimbursement
       through practices that comply will all laws, rules and
       regulatory guidelines
      • Communication with colleagues.
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       EM DOCUMENTATION GUIDELINES -CPT & CMS
   E & M Nature of                                  CPT                              CMS                          RVU
                  Presenting                   Nomenclature                     Quantification                    2020
                  Problem
     99281        Minor;              Problemfocused Hx                 1 HPI- 0 ROS- O PFS Hx                    0.64
                  self limited        Problem focused Exam              1 Organ system exam
                                      Straightforward MDM               Straightforward MDM
     99282        Low                 Expanded problem focused Hx       1HPI-1 ROS-0 PFS Hx                       1.23
                                      Expanded problem focused Ex       2 Organ system exam
                                      Low Complexity MDM                Low Complexity MDM
     99283        Moderate            Expanded problemfocused Hx        1HPI-1 ROS-0 PFS Hx                       1.84
                                      Expanded problem focused Ex       2 Organ system exam
                                      Moderate Complexity MDM           Moderate Complexity MDM
     99284        High                Detailed Hx                       4 HPI- 2 ROS- 1 PFS Hx                    3.38
                                      Detailed Exam                     2+ Organ System Exam
                                      Moderate Complexity MDM           Moderate Complexity MDM
     99285        High                Comprehensive Hx                  4 HPI- 10 ROS- 2 PFS Hx                   4.91
                                      ComprehensiveExam                 8 organ systemexam
                                      High Complexity MDM               High Complexity MDM        3
     Determine the Extent of H & P
     •Medical Necessity of a service is the
      overarching criteria for payment in addition to
      the individual requirements of a CPT Code
     “Medical necessity is defined as accepted health care services and 
     supplies provided by health care entities, appropriate to the evaluation 
     and treatment of a disease, condition, illness or injury and consistent 
     with the applicable standard of care.”
     “Medicare Claims Processing Manual Chapter 12, Section 30.6.1”
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