Can we combine the body areas and organ system to determine the complexity of the examination? The CMS 1995 E/M documentation guidelines use the words 'and' and 'or' on page 10 when referencing how to differentiate the level of complexity of the examination portion of an E/M service.

To address the question regarding the use of the words "and" and "or" in the CMS Evaluation and Management (E/M) guidelines: The guidelines do state that only one type of guideline be used (e.g., 1995 or 1997), and within that guideline only one portion can be defined (e.g., body area or system).

As stated in previous publications, there are two versions of the E/M documentation guidelines: the 1995 version and the 1997 version. The most substantial differences between the two versions occur in the examination documentation section.

The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

Resources: Evaluation and Management Services Guide.

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