Medical Coding Evaluation and Management, 1st edition

For introduction, reinforcement, or education of Evaluation and Management documentation requirements for a wide variety of clinicians in healthcare settings.

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.

Features

Focuses on evaluation and management visits and shows how to interpret documentation, categories, subcategories, and other elements so it is coded accurately.

Offers an in-depth look at the foundational documents of the evaluation and management doctor visit—1995 Documentation Guidelines for Evaluation and Management Service Visits, 1997 Documentation Guidelines for Evaluation and Management Service Visists, and the Current Procedural Terminology (CPT) manual published by the AMA.

Addresses the physical examination in three different chapters—see Chapter 6, Chapter 7 and Chapter 8.

Covers all E/M settings—including clinic office, critical care, hospital observation, preventive medicine, assisted living facility care, etc.

Uses one clinical scenario "Johnny's Irritating Cough" in the first 13 chapters so readers learn to compare the different elements of an E/M documentation.

Includes clinical examples and chapter exercises that build on one another so students can practice identifying coding elements in challenging, clinical documentation.

Introduces coding challenges (Chapters 14-17) that require students to utilize all prior information, the current CPT manual, and critical thinking skills to identify the category and subcategory of the documented evaluation and management service.

Uses consistent formatting in tables throughout the text so students get a meaningful illustration of each evaluation and management element and can more easily develop the content service worksheet.

Includes reader-friendly features such as:

• Chapter Objectives
• Key Terms and Abbreviations
• Medical Documentation Examples
• Exercises
• Figures, Tables and Illustrations
• Chapter Review
• Case Study