How To Use the Evaluation & Management (E&M) Codes Properly:
Part II: A Closer Look at E/M Guidelines
SOURCE: Chiropractic Economics
By Kathy Mills Chang, MCS-P
Part II: A Closer Look at
Evaluation & Management
Make sure you know how to fulfill the “examination” component. In part one of this series, the components of a patient’s history were reviewed, and you learned how it is the first of three elements that help you justify and document your evaluation and management (E/M) service.In the second part of this series, you’ll learn about the objective information required to properly document the examination.
Remember, the medical record establishes a chronological record of exams; tests and results; treatments; and treatment plans, including the diagnosis and prognosis of the illness or disease. Its job is to corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.
For this reason, your medical record is a vital piece of the reimbursement puzzle, too. Understanding all the requirements, including those of the examination, is critical.
There are four levels of E/M services that are based on four types of examinations: (more…)