COMPLETE SOLUTIONS VERIFIED
Documentation requirements related to billing
CC: what the patient is here for "in the patient's own words"
Hx:PMI, PHI
Physical Exam
Medical Decision making
Concerns of the patient and provider should be clearly recorded
Expectations (realistic or not)
Satisfaction or dissatisfaction
INCIDENT TO
services provided to patients by mid-level providers, such as nurse practitioners or
physician assistants, when the physician is on site
CPT Codes
List of descriptive terms and identifying codes to report to medical services and
procedures.
Uniform language to accurately describe all medical, surgical, diagnostic services and
procedures.
E/M Codes: (Evaluation & Management Services)
Primarily used via hospitalist
What are the 3 factors in E/M coding