Three Components Seem So Simple
For each patient-doctor interaction, you, as the medical provider, select the appropriate code that defines history, physical exam, and decision. On its face, basing evaluation and management coding on three elements seems easy. However, each of the components has additional divisions of its own.
Broad Overview of What Medical Coding Is
If you are a healthcare provider, you know the only way Medicare or other medical insurers will reimburse you for your services is if you speak their language. In the medical field, the check writers only understand history, diagnoses, and treatments through a complex coding system. Not only must you know how to classify everything you do in its statistical category, but you must do it in a way to comply with all regulations. An evaluation and management coding tool can facilitate the process, although it still requires human input. Outsourcing your medical coding is a viable option that can free you up for exams, diagnostics, and other hospital functions and release you from concerns about document compliance.
Coding needs to recognize four elements and four levels of history. Components include but are not limited to chief complaint and family history. The system additionally breaks the classification of history into four tiers, which are problem-focused and expanded problem-focused, detailed, and comprehensive.
The physical examination tiers are quite like those for history, but the rules are specific. An exam must follow a designated protocol, and each organ system that has an objective abnormality receives a bullet. Every tier requires a certain number of bullets. For example, a physical exam only falls under the comprehensive category if the physician identifies 12 bullets. Two illustrations of a bullet are a heart murmur and pale mucous membranes. Capable medical coders can use an evaluation and management coding tool as they sift through the doctor’s records.
Think of labor and parts for automobile mechanics. Loosely, the medical decision quantifies a doctor’s amount of labor. Coding defines medical decisions according to the number of diagnoses and treatment options, difficulty reaching a diagnosis via tests and data, and risks of death or complications to the patient. When you use evaluation and management coding, you can classify a medical decision as straightforward or slightly, moderately, or highly complex.
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