Evaluation and Management

2290 Words10 Pages
EVALUATION AND MANAGEMENT E/M coding is the process that physicians, use to translate the patients visit into a five digit CPT( current procedural terminology) codes, so they can submit it to the insurance company for payment. Every procedure has it own CPT codes that describe the different level of care at the time of the physician-patient encounter. Every patient encounter is a unique procedure that requires specific documentation. Each individual E/M code has a set of rules called E/M guidelines. The Center for Medicare and Medicaid Services developed these guidelines (CMS) and the American Medical Association. They released the first version in 1995 and they released the latest version in 1997. Each version has its…show more content…
Evaluation and management services have seven components to define the service they include: history, examination, medical decision making, counseling of care, nature of present problem, and time. When selecting the level of E/M service the key components are history, examination and medical decision-making; unless the visits are mainly for counseling or coordination of care, then time will be the key component for selecting the level of service. The level of E/M service is based on four types of history ( problem focused, expanded problem focused, detailed and comprehensive). Each type will include some or all of the chief complainant(CC) describing the symptoms, problem, or condition, reason for the visit. History of present illness (HPI) describes the location, severity, duration, timing, modifying factors and associated signs and symptoms. Review of systems (ROS) is an inventory of the various body systems that may be related to the patient HPI through questioning. Past, family, or social
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