In Billing
Aug 4th, 2015
by Kerin Draak, CPC, CPC-I, CEMC, COBGC The CPT® codebook defines the Chief Complaint (CC) as “A concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” CPT® recognizes five levels of presenting problems: Minimal, Self-limited or minor, Low severity, Moderate severity ...
Jan 1st, 2011
By Sarah Todt, RN, CPC, CEDC Determining MDM using the 1995 Documentation Guidelines for Evaluation and Management Services and directions from CPT® Evaluation and Management (E/M) Services Guidelines poses unique challenges when coding emergency medicine E/M services. The three key components used in the emergency department (ED) for assigning E/M services include: history, exam, and ...