Evaluation and Management Services

In: Business and Management

Submitted By jetfenn
Words 693
Pages 3
Abstract
Evaluation and management services or E/M is a service used by private health insurance companies, Medicare and Medicaid for the purpose of reimbursement to providers for patient encounters within the United States. E/M is used in determining the type and extent of the condition of a patient. Current Procedural Terminology (CPT) Codes are used in conjunction with E/M codes to document and bill for reimbursement of specific services.

Evaluation and Management Services
To determine the level of evaluation and management services that are provided to a patient, the key components and contributing factors need to be assessed. The procedure would be to identify if the patient is a new or established patient, where the patient is being seen, is this a consultation, is the patient being seen for an illness or preventive care, determine the level of history, the level of examination, the level of medical decision making (MDM), then assign the proper code (Abraham, 2011).
Evaluation and management service levels are based on any and all documentation found in a patient’s medical record. There are different levels of service for which key components are based on; history, examination and medical decision making. These three components are a reflection of what occurred and is recorded by the doctor in the patient’s medical record. You will find these key components in every patients case with the exception of counseling encounters. By using these key components, you are able to decide what level of service to use (Abraham, 2011).
History is what the patient tells the doctor, There are four elements of a history; Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and/or Social History (PFSH). By reading notes the doctor has written in the medical record, a coder would be able to identify the elements…...

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