Auditing E/M Visits in 2025

Understanding Carrier Expectations, Avoiding Common Errors, and Improving Provider Workflows

When Office and Other Outpatient Services saw their major change in documentation rules in 2021, there were many new guidelines and rules to try to understand and adjust to. When the changes to other Evaluation & Management codes occurred, following suit in 2023, we still did not understand well all the changes that had been made.  Now, adding on to the initial set of changes were a few additional ones.  Finally, as we had waited patiently, carriers, through releases on FAQ, articles and audits, gave us little tidbits of information to help clarify what was acceptable to them for documentation in these new rules for E&M services.

As we are now in the fourth year since the initial changes were made to E&M documentation guidelines, we are gaining valuable information about what phrases like “problem addresses”, independent report”, and “prescription drug management” mean for provider’s documentation. 

Providers seem to be having difficulty stopping old habits of documenting complete history and physical exam elements even though that requirement has changed.  Understanding the changes that were made that can save the providers significant time in their documentation and make auditing of those records significantly easier with reasonable changes in documentation.  One of the major issues is provider’s seeming reliance on drop-down documentation and pre-populated templates instead of, oftentimes, quicker narrative documentation.

The session will walk through the Elements of Decision-Making table. It will review the requirements of the differing levels of service (e.g., low and moderate). Then, it will discuss frequently incorrect documentation and offer documentation tips for educating providers. 

Webinar Agenda

• Understanding the First Column (Problems Addressed)
  • Discussion of documentation rules and policies related to medical decision-making.
• Exploring the Middle Column (Amount and/or Complexity of Data to be Reviewed)
  • Identification of complicated items in this section.
  • Explanation of nuances related to historian and personal interpretation in documentation.
• Reviewing the Risk Column
  • Clarification that risk refers to the treatment’s impact on the patient, not just the illness itself.
  • Differentiation between treatment risk and disease risk.
  • Discussion of elements such as prescription drug management and social determinants of health.

Webinar Highlights

• Table of the Elements of Medical Decision Making
• Description of each of the three columns
• Documentation requirements of each
• Time-based code selection and its documentation requirements
• Pitfalls in documentation, what simple notations can tank a note and cause it to fail an audit

Who Should Attend

Coders, Billers, Auditors, Compliance, Office Manager, Office Administrator