Nurs 6565 Week 8 Discussion Coding: Evaluation And Management (E/m)

This study source was downloaded by 100000857300661 from CourseHero.com on 12-13-2022 12:38:11 GMT -06:00https://www.coursehero.com/file/38477967/WK8DBdocx/ Coding: Evaluation and Management (E/M)In medical field, if it is not documented in the patient chart that means it has neverbeen done. Documentation plays an important role. Clear and concise medical record documentation is critical to providing patients with quality care and is required for you toreceive accurate and timely payment for furnished services (Centers for Medicare & Medicaid Services, 2017). The chart should be able to show records or events they way they occurred from patient received, pertinent fats, what were the findings, and provider observations. The principle remains the same for all type of medical settings either it is clinic or surgical services. Many E/M services varies in several ways, such as the nature and amount of physician, PA, or NPs work required, these general principles help ensure that medical record documentation for all E/M services is appropriate:1. The medical record should be complete and legible 2. If the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred3. Past and present diagnoses should be accessible to the treating and/or consulting physician4. Appropriate health risk factors should be