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Five not-so-black-and-white E/M coding rules

When it comes to E/M coding, the rules are clear-that is, unless what you're coding happens to fall into a gray area. E/M codes are especially detailed (and complex) and, as with all codes, rely entirely on documentation. But just because the rules are out there doesn't mean that physicians follow or understand them, says Wanda Ziemba, MFA, BA, RHIT, CPC, E/M auditor and full-time faculty member of the health information technology department at Chabot College in Hayward, CA.