How To Use the Evaluation & Management (E&M) Codes Properly:
Part III: Mastering the E/M Guidelines
SOURCE: Chiropractic Economics
By Kathy Mills Chang, MCS-P
Part III: Mastering
the Evaluation & Management
The medical decision making component ties it all together.
Welcome to part three this focus series on the evaluation and management (E/M) guidelines. This will wrap up what you need to know to stay compliant with E/M coding for the Centers for Medicare and Medicaid Services (CMS).
In the last installment, the elements of your patient’s examination were reviewed and you learned how it is the second of the three key elements of the patient’s E/M service. Now, the third part of this E/M documentation series will unravel the final component of the E/M code: medical decision making (MDM). For chiropractors, this is usually the diagnosis and treatment plan.
Three key components of the E/M guidelines:
- Patient history
- Medical Decision Making (MDM)
Remember that your patient’s medical record should establish a chronological record of exams, tests and results, and treatments and treatment plans (including the diagnosis and prognosis of the illness or disease). The medical record should corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question. (more…)