Medical Coding Evaluation and Management / Edition 1

by Kate Gabriel-Jones, Larry Bohn

Overview

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.

Product Details

ISBN-13:	9780132881562
Publisher:	Pearson Education
Publication date:	01/11/2013
Edition description:	New Edition
Pages:	320
Product dimensions:	8.40(w) x 10.70(h) x 0.60(d)

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