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Printed Date: 9/22/2015
"More detail" refers to the extent of the exam. The level of detail involved in an exam is a clinical judgment based on the documentation for each individual medical record. There is an expectation that the exam will be more involved, and therefore more documentation would be submitted for a detailed exam. The documentation for a detailed exam would consist of at least two findings for at least two body areas or two organ systems.
Resource: CMS MLN Evaluation and Management Services Guide
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Last Updated: 06/26/2020