ACOEM Proposed Alternative Documentation Criteria for Evaluation and Management Encounters

Medical care should be focused on more than symptom reduction – ideally, medical encounters should support the restoration of normal life activities, including participation in school, work, family and society. Attending to function as a vital sign will increase the value of medical care in every clinical setting in which impairment or disability is an issue or potential issue. The documentation that is presently required by the Evaluation and Management (E/M) codes to support requests for reimbursement does not have an optimal functional focus. Specifically, the current E/M criteria call for documenting a multitude of historical and examination elements that do not include the factors shown by research to prevent excessive and often harmful medical care, prolonged disability and other poor outcomes. Because the current coding system does not reimburse providers for documentation of such critically important data elements, there is often insufficient attention to these issues in encounters, with resultant preventable problem outcomes. For this reason, ACOEM's Council on Occupational and  Environmental Medicine Practice has developed a proposed functionally oriented approach for documenting E/M encounters. This approach been designed to fit into the current coding paradigm and levels of care, by making minor but important substitutions in specific elements of history, physical examination and medical decision-­‐making, consistent with research evidence for better clinical outcomes, including promoting optimal participation in social roles. 
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