Awareness : OBC Tips

Evaluation and Management (E/M) Coding: Volume of Documentation Versus Medical Necessity

Evaluation and Management (E/M) Coding:    Volume of Documentation versus Medical Necessity

  • Even if a “complete” note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter, as documented, can be considered when selecting the appropriate level of an E/M service.
  • Information that has no pertinence to the patient’s situation at that specific time cannot be counted.