Coding: Evaluation and Management (E/M)
In medical field, if it is not documented in the patient chart that means it has never
been done. Documentation plays an important role. Clear and concise medical record
documentation is critical to providing patients with quality care and is required for you to
receive accurate and timely payment for furnished services (Centers for Medicare &
Medicaid Services, 2017). The chart should be able to show records or events they way
they occurred from patient received, pertinent fats, what were the findings, and provider
observations. The principle remains the same for all type of medical settings either it is
clinic or surgical services. Many E/M services varies in several ways, such as the nature
and amount of physician, PA, or NPs work required, these general principles help ensure
that medical record documentation for all E/M services is appropriate:
1. The medical record should be complete and legible
2. If the rationale for ordering diagnostic and other ancillary services is not
documented, it should be easily inferred
3. Past and present diagnoses should be accessible to the treating and/or consulting
physician
4. Appropriate health risk factors should be identified
5. The patient’s progress, response to and changes in the treatment, and revision of
diagnosis should be documented
6. The diagnosis and treatment coeds reported on the health insurance claim form or
billing statement should be supported by documentation in the medical record
7. The documentation of each patient encounter should include:
a. Reason for the another and relevant history, physical examinations
findings, and prior diagnostic test results
b. Assessment, clinical impression, or diagnosis
c. Medical plan of care
d. Date and legible identity of the observer
(Centers for Medicare & Medicaid Services, 2017).
This study source was downloaded by 100000857300661 from CourseHero.com on 12-13-2022 12:38:11 GMT -06:00
https://www.coursehero.com/file/38477967/WK8DBdocx/
In medical field, if it is not documented in the patient chart that means it has never
been done. Documentation plays an important role. Clear and concise medical record
documentation is critical to providing patients with quality care and is required for you to
receive accurate and timely payment for furnished services (Centers for Medicare &
Medicaid Services, 2017). The chart should be able to show records or events they way
they occurred from patient received, pertinent fats, what were the findings, and provider
observations. The principle remains the same for all type of medical settings either it is
clinic or surgical services. Many E/M services varies in several ways, such as the nature
and amount of physician, PA, or NPs work required, these general principles help ensure
that medical record documentation for all E/M services is appropriate:
1. The medical record should be complete and legible
2. If the rationale for ordering diagnostic and other ancillary services is not
documented, it should be easily inferred
3. Past and present diagnoses should be accessible to the treating and/or consulting
physician
4. Appropriate health risk factors should be identified
5. The patient’s progress, response to and changes in the treatment, and revision of
diagnosis should be documented
6. The diagnosis and treatment coeds reported on the health insurance claim form or
billing statement should be supported by documentation in the medical record
7. The documentation of each patient encounter should include:
a. Reason for the another and relevant history, physical examinations
findings, and prior diagnostic test results
b. Assessment, clinical impression, or diagnosis
c. Medical plan of care
d. Date and legible identity of the observer
(Centers for Medicare & Medicaid Services, 2017).
This study source was downloaded by 100000857300661 from CourseHero.com on 12-13-2022 12:38:11 GMT -06:00
https://www.coursehero.com/file/38477967/WK8DBdocx/
