Medical Record Documentation for E/M Services

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City Vermont
State Vermont
Country United States
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Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care.  The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are history; examination; medical decision making; counseling; coordination of care; nature of presenting problem; and time. The first three of these components (i.e., history, examination, and medical decision making) are the key components in selecting the level of E/M services. In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service. Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service. To know more visit us: http://bit.ly/33qzsgH or email us at- [email protected] or call us at- 888-357-3226 (Eight-Eight-Eight-Three-Five-Seven-Three-Two-Two-Six).

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