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Daily Archives: September 9, 2011

How To Use the Evaluation & Management (E&M) Codes Properly: Part I

By |September 9, 2011|Evaluation & Management, Guidelines|

How To Use the Evaluation & Management (E&M) Codes Properly:

Part I: The 3 Key Components of the E/M Guidelines

The Chiro.Org Blog


SOURCE:   Chiropractic Economics

By Kathy Mills Chang, MCS-P


Part I:   The 3 Key Components of
the Evaluation & Management
(E&M) Guidelines

Jump to:   Part 2 or Part 3

In order to document your history, diagnosis, and treatment of patients in accord with rules set out by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), your patient record should address: (1) Patient history, (2) Examination, and (3) Medical decision-making (MDM). These three components are addressed in the following three articles, which also make reference to the Sample Worksheet included with Part III

As regulatory and insurance guidelines tighten, the quality of your evaluation and management documentation is more important than ever before.

Just like a great story, the patient’s notes for an episode of care must have a beginning, middle, and end. This article is a review of the first of three parts of evaluation and management (E/M) documentation, and its focus is on the beginning of the patient’s story — the history. More information on the next two key E/M components will be presented in future issues of this magazine. (more…)