For additional information or questions on coding, billing and auditing, contact Antanya Chung, CPC, CPC-I, CRHC, CCP, at [email protected].
Related Articles
Documentation Guidelines for Proper Medical Decision Making
The Medical Decision Making (MDM) of an evaluation and management (E/M) visit is one of the three components of determining the level of a patient’s visit. But the MDM can sometimes be the most difficult component, as this is where the provider’s thought process is quantified in deciding the correct level of E/M service. In the…
Electronic Health Record Documentation Guidelines
The operations management team in healthcare practices is expected to have an effective coding compliance program in place that is continually evaluated and reevaluated. To accurately assess the program’s effectiveness, several outcome indicators must be measured, including error rates in the provider’s documentation and the electronic health record (EHR). Due to increased scrutiny by the…
How to Document a Patient’s Medical History
The levels of service within an evaluation and management (E/M) visit are based on the documentation of key components, which include history, physical examination and medical decision making. The history component is comparable to telling a story and should include a beginning and some form of development to adequately describe the patient’s presenting problem. To…
Elements of Medical Decision Making for Rheumatologists When Coding and Billing
What rheumatologists need to know about determining the level of medical decision making (MDM) for an office visit