EVALUATION AND MANAGEMENT
E/M coding is the process that physicians, use to translate the patients visit into a five
digit CPT( current procedural terminology) codes, so they can submit it to the insurance
company for payment. Every procedure has it own CPT codes that describe the different level of care at the time of the physician-patient encounter. Every patient encounter is a unique procedure that requires specific documentation. Each individual E/M code has a set of rules called E/M guidelines. The Center for Medicare and Medicaid Services developed these guidelines (CMS) and the American Medical Association. They released the first version in 1995 and they released the latest version in 1997. Each version has its advantages and disadvantages, and mixing and matching the two sets of rules within the same medical documentation is not acceptable. Understanding the difference between the two guidelines and their unique set of rules that apply to them is very important.
Medical records are used to document facts, findings and observations about an individual health history, both past and present illnesses, examinations, tests, treatments, and outcome. The medical record documents the care of the patient and is important to the quality of care the patient receives. The medical records make it easier:
For the physician and other health care professionals to evaluate and plan the patient’s treatment, and to monitor their health overtime ▸
Provide communication and constant care between physicians and other health care professionals that participate in the care of the patients ▸
Make accurate and timely claims and reviews and payment
For reviews and quality of care evaluations
For collection of information that can be of use for research and education Because insurance companies have an obligation to their enrollees, they require documentation of services that are consistent with the coverage that they provide; the site of service, medical necessity and appropriate diagnostic or therapeutic services, and to making sure the services where documented and reported accurately. Each patient encounter should include reason for visit and relevant history, physical exam findings and any prior test results. It should also include the reason for ordering diagnostic and other services, clinical impression or diagnosis and medical plan of care, date and identity of the physician. The three categories for office visits, is the new patient, established patient and the office consults. A new office patient is someone whom a physician has never seen in the same speciality or group in the last three years. There are five levels of care for a new patient encounter. Level of care
Physical Exam Medical Decision Making Time 99201 Problem focused
Problem focused Straightforward 10 99202 Expanded PF Expanded PF Straightforward 20 99203 Detailed Detailed Low 30 99204 Comprehensive Comprehensive Moderate 45 99205 Comprehensive Comprehensive Moderate 60 Documentation of all three key components is needed for any given level of care of a new patient. Established office patient is someone whom the physician has seen in the same speciality or group within the last three years. There are also five levels of care for the established office patient.
Level of care
Physical Exam Medical Decision Making Time 99211 None None None 5 99212...
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