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Medical Coding Evaluation and Management



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Thorough and correct documentation of evaluation and management services provide the foundation for correct billing. Medical Coding Evaluation and Management, 1e provides an easy-to-read reference tool for thorough and effective documentation of any evaluation and management service visit. By focusing on the foundations of evaluation and management documentation guidelines, physicians, non-physician providers and other clinicians have the opportunity to understand the complexities of documenting any evaluation and management service correctly. Highlighting a variety of settings, readers learn about how to document medical history, physical examinations, medical decision-making, counseling and/or coordination of care, as well as intraservice time. Clinical examples, a clinical scenario and chapter exercises round out coding skills, as readers learn to dissect the evaluation and management visit and all its elements.

Table of Contents

1.      Evaluation and Management: An Overview

2.      History of Present Illness (HPI)

3.      Review of Systems (ROS)

4.      Past, Family, Social History (PFSH)

5.      Selecting the Overall History Level: Putting HPI, ROS, and PFSH Together

6.      Physical Examination: The 1995 Physical Exam

7.      Physical Examination: The 1997 General Multi System Physical Exam

8.      Physical Examination: The 1997 Single Organ System Physical Exam

9.      Medical Decision Making: Number of Diagnosis and/or Management Options

10.  Medical Decision Making: Complexity of Data Reviewed

11.  Medical Decision Making: The Risk of Complication, Morbidity, or Mortality

12.  Selecting the Overall Medical Decision Making Level

13.  Putting All the Elements Together to Find the Right E/M Code

14.  Evaluation and Management Guidelines: Categories Requiring Content of Service

15.  Evaluation and Management Guidelines: Case Management, Care Plan Oversight, Preventive Medicine, Non-Face-to-Face Physician Services, Domiciliary or Home Care Plan Oversight, and Special Services

16.  Evaluation and Management Guidelines: Categories Requiring Something More: Prolonged Services, Newborn Care, and Critical Care

17.  Evaluation and Management Modifiers

18.  Evaluation and Management Resources and Summary


APPENDIX A: Instructions for Accessing the 1995 Documentation Guidelines for Evaluation and Management Services

APPENDIX B: Instructions for Accessing the 1997 Documentation Guidelines for Evaluation and Management Services

APPENDIX C: The Anatomy of the Evaluation and Management Medical Documentation

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