Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
You get one data point for "deciding" to obtain old records. In order to claim this point you must document your specific intentions in the chart. Many physicians routinely decide to get old records, but forget to mention it in the note. This is a fairly easy data point to pick up.
