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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.
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You can get one data point for discussing a test with the performing physician. For example, if you speak with the cardiologist who interpreted an echo cardiogram, or if you discuss the results of an endoscopy with the performing gastroenterologist.
It is important to remember that you must document that the discussion occurred and summarize the findings in the chart in order to take credit for this type of cognitive labor.
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