In Audit
May 27th, 2015
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA During a recent meeting with approximately 40 providers, I asked how many had billed a level 5 evaluation and management (E/M) visit in the last month.  Not one hand was raised.   How about the last 6 months?   A few hands went up but each of them ...
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 ...
Aug 1st, 2009
By Katherine Abel, CPC, CPC-I, CMRS In this three-part series on the driving components of level selection for the majority of evaluation and management (E/M) services, we discuss history, examination, and medical decision making (MDM). In this final installment, we’ll focus on the MDM component. MDM is perhaps the most important of the three primary ...