Revenue Cycle Insider

A few specific details in your practitioner’s notes can make all the difference.

When it comes to evaluation and management (E/M) coding, the final code choice doesn’t always hinge on a single diagnosis or a copied and pasted note. It often depends on whether the record clearly supports the work behind the visit. From clear medical notes, patient case updates, and the complexity of problems addressed, coders need documentation that captures the provider’s thought process without forcing them to guess the missing details.

In this first installment of a two-part series, this expert-driven HEALTHCON 2026 presentation, “Expert E/M Insights: Cracking the Code of the Three Key Elements of MDM” led by Pam D’Apuzzo, CPC, CPMA, ACS EM, ACS MS, Betsy Nicoletti, MS, CPC, and Debra Rossi, CPC, CPMA, breaks down how clearer E/M documentation can help teams choose the right medical decision making (MDM) level, avoid common copy-and-paste pitfalls, and support stronger, more accurate claims.

Keep reading to learn what E/M experts say coders and providers should focus on to strengthen documentation and coding accuracy.

Know the 3 Ms of Medicare

Rossi explained that with so many tools available to us now like copy and paste, smart phrases, and macros, it’s becoming more important than ever to prove the three Ms of Medicare for each patient’s visit. To prove the three Ms, you need to ask yourself these questions about the service:

• Medically necessary — Why is the patient being seen?
• Medically justified — Are the services that are being performed or the tests that are being ordered justified?
• Medically reasonable — Are the services reasonable for the presenting problems of the patient?

Tally Number and Complexity of Problems Addressed

CPT^® divides complexity of problems addressed (COPA) into four distinct levels: minimal, low, moderate, and high. Some examples of moderate COPA include chest pain, abdominal pain, back pain, shortness of breath, vomiting, diarrhea, dizziness, weakness, and headache.

Examples of high COPA include stroke, acute respiratory failure, septic shock, severe COPD exacerbation, hypertensive emergency, etc.

“For some of those edge cases, it’s not about the condition failing to fall into a certain category, but it’s about the documentation not always being 100 percent clear,” D’Apuzzo said.

The documentation focus is going to be on the presenting symptom, differential diagnosis, and complexity of problems. D’Apuzzo pointed out that most of the information you’ll need related to COPA is found in the CPT^® code book’s parentheticals. She also went on to say one of the big improvements with the E/M updates in 2021 and 2023 guidelines occurred with the definitions.

“There is still going to be complexity — you’ll really have to look into it and read that note to be able to determine the level of service; but having a definition including words like ‘stable,’ ‘chronic,’ or something that is expected to last 12 months or for the lifetime of the patient, that’s really helpful, but that’s not what is in the note. You still need to understand what falls into the category of [each] condition,” D’Apuzzo said.

She went on to say that it’s important to share the importance of these documentation variations with your providers as sometimes this could mean the difference between a moderate- or high-complexity payout.

“The note is all they have to defend what it is they are doing for that patient. That note has to properly convey [everything] without us inferring that information on behalf of the provider,” D’Apuzzo said.

Teach Your Team E/M Documentation Essentials

To help clear up any confusion when reviewing practitioner’s notes for E/M visits, D’Apuzzo suggested sharing with your physicians how you as a coder and biller use their notes to create your claim. Explaining to them the importance of including the following information in their notes can help clear up any gray areas for both of you when trying to choose E/M codes in the future:

• Link each problem to an assessment or plan documenting the status, severity, and what management steps were taken today during the appointment.
• State goals for chronic conditions and make it clear in the notes if the patient is on target.
• For a new or undiagnosed problem, document why the prognosis is uncertain and what is being considered.
• Explain how comorbidities influence the workup, treatment, or decision making during the visit.

“[Practitioners] need to be able to convey to us what their thought process is and what they are considering or ruling out for that patient and why,” she said.

Understand What Auditors Look For

With most offices using electronic records for everything, there is a convenience to copy and pasting, but also a danger. Auditors are always looking for patterns proving that practitioners aren’t fully invested in the information in a patient’s file and are just adding a few new sentences here and there to save time. D’Apuzzo shared a list of problems and solutions to remedy these copy and paste issues in your office:

Problem list copied forward with no status update

• Ensure each problem includes current status and today’s plan, with clear link to actions (for example, medication changes, tests, referrals, shared decision to defer, etc.)
• Justify medical necessity (for example, show a response to therapy or medication)

‘Chronic condition stable’ but not at goal

• Specify the clinical goal, the variance, and the patient’s current status, supported by measurable data (vitals, labs, symptoms, etc.)
• Clearly state the target goal (for example, A1c goal or body mass index [BMI] goal)
• Show how the patient’s condition changed from the last visit

Comorbidities listed without relevance

• Document how each comorbidity impacted today’s E/M service (for example, diagnostic choices, treatment modifications, or monitoring level)

Vague clinical descriptors used

• Replace these with clear clinical details and explicit next steps (for example, severity, progression, response to therapy, planned follow-up)

“If I’m just copying and pasting the history from the last visit with no update [on the patient] today, I can’t make a determination without [the practitioner] giving me some update. I need to know what is going on with them today,” D’Apuzzo said.

Helping providers understand the value of detailed, precise documentation enables coding teams to assign the correct E/M level, improve coding accuracy, and support appropriate reimbursement.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC