Evaluation and Management Guidelines

The Department of Workers’ Compensation’s (DOWC) included this exhibit for 2012 to improve both the level of content and medical record documentation for E&M services. Exhibit 7 outlines documentation requirements to justify the billed level of E&M service. These requirements are consistent with Common Procedural Terminology (CPT) guidelines and incorporate determinations more specific to occupational medicine. They are also consistent with Medicare’s 1997 E&M documentation guidelines.

Exhibit 7 allows for determination of level of service based on either the documentation of the three relevant key components — History, Exam, and Medical Decision Making — or the documented time if greater than 50 percent of the face-to-face visit involves counseling and coordination of care (time must be documented). Some specific language includes, “Documentation must be patient specific and pertain directly to the current visit. Information copied directly from prior records without change is not considered current nor counted.”

To view the complete Exhibit 7, go to www.coworkforce.com and access Rule 18 under the Rules of Procedure including Medical Treatment Guidelines section, then click on Exhibit 7.