Even as the public health emergency continues and patient volumes are disrupted, the Evaluation & Management Essentials will assist you in staying on top of rules and guidelines to ensure compliant charges and capturing full compliant payment for E&M services.
$197.00
Amid the continuing challenges inherent with charging and billing for evaluation and management (E&M) services, you can quickly get the answers you need from the new edition of our Evaluation & Management Essentials book. Fully updated for 2022, this proven resource covers all the changes to codes, guidelines and documentation requirements. Plus, you’ll find guidance with the new calculations for selecting a level of service based on time or medical decision-making — which initially are applicable only to office visits, meaning there’s a different set of guidelines for hospitals and other settings.
This time-tested resource is ideal for coders, audit and compliance staff, physicians, clinic staff and others; it’s designed to clear up the confusion and instill confidence in confronting many changes.
Updated and expanded content, including:
Resources to stay compliant with current guidelines:
Expert tools for practical application of E&M guidelines and code selection:
**Please note that eBooks cannot be printed, and all sales on eBooks are final. If you would like a printed copy of this resource please select the Print version and allow time for shipping.
What Is Documentation Official Principles of Documentation Baseline Data Initial Examination Advance Directives Documenting Tests, Services and Procedures Ancillary Tests Services and Procedures Documenting Telephone Calls Tracking Time Correspondence Between Healthcare Professionals Altering the Medical Record Keeping It Neat What to Include Fraud and Abuse Malpractice Documentation Formats SOAP Notes Preprinted Forms Electronic Medical Record Templates Scribed Services Example of a Scribed Service Signature Requirements Handwritten Signatures Electronic Signatures Evaluate Your Medical Records Medical Record Documentation Questionnaire What has Changed? Medical Decision Making (MDM): Selecting a Level of Service Number/Complexity of Problem(s) Addressed During the Encounter Amount/Complexity of Data to be Reviewed and Analyzed Risk of Complications, Morbidity/Mortality of Patient Management Decisions Made at the Visit Medical Decision Making: Putting it All Together Medical Decision Making Table Time: Selecting a Level of Service Prolonged Service Codes: 2021 Office and Other Outpatient Visits Summary of 2021 E&M Office or Outpatient Services Guidelines Summary of Guideline Differences Step-by-Step Documentation Components of E&M Services The History Chief Complaint History of Present Illness Review of Systems Past, Family and Social History The Examination Content and Documentation Requirements 1995 Guidelines Versus 1997 Guidelines 1997 Examination Guidelines Single Organ System Examinations Ear, Nose and Throat Examination Hematologic/Lymphatic/Immunologic Examination Musculoskeletal Examination Neurological Examination Psychiatric Examination Respiratory Examination Skin Examination The Complexity of Medical Decision-Making Number of Diagnoses or Management Options Amount and/or Complexity of Data to be Reviewed Risk of Complications and/or Morbidity or Mortality Counseling or Coordination of Care Hospital Services Documentation for Incident-To Services Examples of Proper Use of the 25 Modifier Examples of Improper Use of the 25 Modifier Key Points Examples of Related Diagnoses Examples of Unrelated Diagnoses Introduction Documentation Requirements Primary Care Exception Minor Procedures Performed in the Office Setting Psychiatry Time-Based Codes Teaching Physician Modifiers Online Digital Evaluation and Management Services Qualified Nonphysician Health Care Professional Online Digital Evaluation and Management Services Interprofessional Telephone/Internet/Electronic Health Record Consultations Digitally Stored Data Services/Remote Physiologic Monitoring Remote Physiologic Monitoring Treatment Management Services Communication Technology-Based Services Telehealth Services and CMS Telehealth Services During the Public Health Emergency (PHE) Preventive Care Preventive Medicine Services (99381–99397) Modifier 33 Medicare Preventive Services Initial Preventive Physical Exam (IPPE) Important Reminders Nine Components of IPPE Annual Wellness Visit Sample Health Risk Assessment Breast And Pelvic Screenings (G0101) Screening Hemoccults (G0328) Preventive Counseling/Risk-Factor Reduction Tobacco Use Cessation Counseling Baseline Data Medication and Problem Lists Allergies and Adverse Reactions Pediatric Preventive Screening Immunizations Immunization Administration for Vaccines/Toxoids Health Education and Counseling Medical Reviews What Encourages a Review? Policy Development The Many Faces of a Medical Review Consequences of Claim Errors False Claims Act To Get a Passing Grade Types of Appeals Office or Other Outpatient Services (99202–99205, 99211–99215) Hospital Observation Services (99217–99226) Hospital Inpatient Services (99221–99223, 99231–99233) Observation or Inpatient Care Services (Including Admission and Discharge Services) (99234–99236) Hospital Discharge Services (99238–99239) Consultations Office or Other Outpatient Consultation, New or Established Patient (99241–99245) Inpatient Consultation, New or Established Patient (99251–99255) Emergency Department Services (99281–99285) Emergency Department Services – Facility Component (99281–99285) Critical Care Services (99291–99292) Nursing Facility Services (99304–99318) Initial Nursing Facility Care (99304–99306) Subsequent Nursing Facility Care (99307–99310) Nursing Facility Discharge Services (99315–99316) Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services (99324–99337) Domiciliary, Rest Home (e.g., Assisted Living Facility), or Home care Plan Oversight Services (99339–99340) Home Services (99341–99350) Prolonged Services With Direct Patient Contact (99354-99357) Prolonged Service Without Direct Patient Contact (99358–99359) Prolonged Clinical Staff Services with Physician or Other Qualified Healthcare Professional Supervision Prolonged Service With or Without Direct Patient Contact on the Date of an Office or Other Outpatient Service (99417) Office or Other Outpatient Services – New Patient (99205) Office or Other Outpatient Services – Established Patient (99215) Comparison of Prolonged Service Codes (99354, 99355, 99356, 99358, 99359, 99417) Case Management Services Home and Outpatient International Normalized Ratio (INR) Monitoring Services Medical Team Conference Care-Plan-Oversight Services (99374–99380) Newborn Care Services Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services Initial and Continuing Intensive Care Services Cognitive Assessment and Care Plan Services Care Management Services Chronic Care Management Services Complex Chronic Care Management Services Principle Care Management Psychiatric Collaborative Care Management Services Transitional Care Management Services General Behavioral Health Integration Care Management Sample Documentation for Code 99202 Sample Documentation for Code 99203 Sample Documentation for Code 99204 Sample Documentation for Code 99205 Sample Documentation for Code 99211 Sample Documentation for Code 99212 Sample Documentation for Code 99213 Sample Documentation for Code 99213 Sample Documentation for Code 99214 Sample Documentation for Code 99214 Sample Documentation for Code 99215 Sample Documentation for Code 99221 Sample Documentation for Code 99223 Sample Documentation for Code 99231 Sample Documentation for Code 99231 Sample Documentation for Code 99232 Sample Documentation for Code 99241 Sample Documentation for Code 99242 Sample Documentation for Code 99253 Sample Documentation for Code 99253 Sample Documentation for Code 99255 Sample Documentation for Code 99281 Sample Documentation for Code 99282 Sample Documentation for Code 99283 Sample Documentation for Code 99284 Sample Documentation for Code 99285 Sample Documentation for Code 99415 Sample Documentation for Code 99483 Sample Documentation for Code 99490 Sample Documentation for Code 99492 Sample Documentation for Code 99493 Sample Documentation Forms Self-Audit FormIntroduction to Evaluation and Management
Chapter 1: Documentation and the Medical Record
Chapter 2: Documenting and Selecting E&M Services for Office and Other Outpatient Visits
Chapter 3: Documenting and Selecting Other E&M Services
Chapter 4: Shared/Split Care and Incident-To
Chapter 5: Modifiers for E&M
Chapter 6: Teaching Physician Guidelines for E&M
Chapter 7: Telehealth/Telemedicine Services
Chapter 8: Preventive Services
Chapter 9: Pediatric Medical Records
Chapter 10: Reviews and Appeals
Appendix 1: Categories of E&M Services
Appendix 2: Sample Documentation for E&M Codes
Appendix 3:
Product SKU | PDOC |
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Product Categories | Books |
Specialties and Topics | Compliance, HIM |
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