The American Medical Association (AMA), in conjunction with the Centers for Medicare & Medicaid Services (CMS) effective Jan. 1, 2021, enacted guideline and code descriptor changes for Evaluation and Management (E/M) services (codes 99202-99215). 

Code selection is based on medical decision-making (MDM) or total time on the date of the encounter. Medically appropriate history and/or examination no longer is a part of the basis for code selection; however, history and exam findings that are pertinent to the visit should still be documented. 

Learn how to document Traditional Medicine decision-making to determine and support appropriate coding levels. Examples of SOAP notes for acupuncture and herbs including telehealth appointments will be discussed in detail.

Galina Roofener works for the Cleveland Clinic as an acupuncturist and Chinese herbalist and is a Nationally Board Certified, Ohio & Florida States Licensed Acupuncturist and Chinese Herbalist. She serves on the State Medical Board of Ohio’s Acupuncture and Oriental Medicine Advisory Panel on the subject of Chinese herbs and other modalities of Oriental Medicine; is a member of the Hospital-Based Practice Task Force Committee advisory panel for the National Certification Commission on Acupuncture and Oriental Medicine and a member of the American Society of Acupuncturists Herbal Committee. 

Galina can be contacted at www.AsianTherapies.org