Evaluation & Management

How To Use the Evaluation & Management (E&M) Codes Properly:

Part II: A Closer Look at E/M Guidelines

The Chiro.Org Blog

SOURCE:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

Part II:   A Closer Look at
Evaluation & Management
(E&M) Guidelines

Jump to:   Part 1 or Part 3

Make sure you know how to fulfill the “examination” component. In part one of this series, the components of a patient’s history were reviewed, and you learned how it is the first of three elements that help you justify and document your evaluation and management (E/M) service. In the second part of this series, you’ll learn about the objective information required to properly document the examination.

Remember, the medical record establishes a chronological record of exams; tests and results; treatments; and treatment plans, including the diagnosis and prognosis of the illness or disease. Its job is to corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.

For this reason, your medical record is a vital piece of the reimbursement puzzle, too. Understanding all the requirements, including those of the examination, is critical.

There are four levels of E/M services that are based on four types of examinations: (more…)

How To Use the Evaluation & Management (E&M) Codes Properly:

Part I: The 3 Key Components of the E/M Guidelines

The Chiro.Org Blog

SOURCE:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

Part I:   The 3 Key Components of
the Evaluation & Management
(E&M) Guidelines

Jump to:   Part 2 or Part 3

In order to document your history, diagnosis, and treatment of patients in accord with rules set out by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), your patient record should address: (1) Patient history, (2) Examination, and (3) Medical decision-making (MDM). These three components are addressed in the following three articles, which also make reference to the Sample Worksheet included with Part III

As regulatory and insurance guidelines tighten, the quality of your evaluation and management documentation is more important than ever before.

Just like a great story, the patient’s notes for an episode of care must have a beginning, middle, and end. This article is a review of the first of three parts of evaluation and management (E/M) documentation, and its focus is on the beginning of the patient’s story — the history. More information on the next two key E/M components will be presented in future issues of this magazine. (more…)