April 21, 2021
E & M Documentation Education: Problems Addressed
Evaluation and Management (E&M) for the ambulatory environment underwent a major overhaul in 2021. We know this is a major adjustment at a time when there is already too much upheaval. We are committed to supporting you with the information you need, in different mediums (written, visual, podcast, and full presentation), in different levels of intensity and time commitment, and with content that will evolve as we learn together.
The new regulation up-ended our definition of the problems we are managing – from the previously simple “new” or “established” to 9 unique and brand new definitions. The good news is that these break down fairly easily to either chronic, acute, simple/self-limited, life/limb-threatening, and undiagnosed. You can get appropriate categorization of the problems you are managing by adopting simple habits of using important buzzwords. Check out the brief slide deck on problems, listen to our brief problems podcast , or print out the one page handout on the buzzwords to remember.
Problem Buzzwords:
- Status of condition: Exacerbated or progressed
- Status of condition: acute or chronic (previously new or established)
- Multiple treatment options
- Requires additional evaluation
- Side effects from treatment
- Risks or morbidity without treatment or from treatment itself
- Severe exacerbation
- Threat to life or bodily function
Many simple reference handouts have been created trying to get you the information you need at your finger tips when you need to reference it in your busy day. The MASTER handout is E&M Documentation Guidelines and Definitions for 99202—99215. Keep this one handy and check out the additional one-page items for helpful information.