Medical Coding Evaluation and Management

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  • Edition: 1st
  • Format: Paperback
  • Copyright: 2013-01-11
  • Publisher: Pearson

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Supplemental Materials

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  • The New copy of this book will include any supplemental materials advertised. Please check the title of the book to determine if it should include any access cards, study guides, lab manuals, CDs, etc.
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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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