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Last Modified: 6/10/2020 Location: FL, PR, USVI Business: Part A, Part B

Documentation support FAQ

Q: Can I use the E/M interactive worksheet as documentation to support my selection of a particular E/M code?
A: No. The E/M interactive worksheet can only calculate a recommended E/M code. The E/M interactive worksheet bases its calculations on the requirements specified in the E/M Documentation Guidelines for Evaluation and Management Services (1995 or 1997) and the selections made by the user.
The E/M interactive worksheet was created as a tool to assist providers and is not intended as a replacement for the 1995 and 1997 E/M documentation guidelines published by the Centers for Medicare & Medicaid Services (CMS). It may not be used as a substitute for documentation supporting the selection of the E/M code in a patient’s medical record.
Note: It is the responsibility of the provider of services to ensure the correct submission of claims and responses to any remittance advice. Therefore, providers should refer to CMS' official documentation guidelines for final E/M code selection and to the American Medical Association's (AMA) Current Procedural Terminology® manual to identify E/M codes that are based upon time.
Sources: 1995 Documentation Guidelines for Evaluation & Management Services
1997 Documentation Guidelines for Evaluation and Management Services
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First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.