Practice Essentials

Electronic Health Record System (EHR)

An Electronic Health Record System (EHR) is the digital system used to store patients’ medical information. EHRs provide a higher level of security for patient information and access to patient records in real time, for authorized users.

E/M Coding

Evaluation and management (E/M) coding refers to the practice of classifying services provided by physicians as they evaluate patients and provide medical treatment.

Specific numerical codes designate the service provided as well as the levels of care which is dependent on the complexity of a patient case. For example, a patient requiring physician standby in the event his or her condition destabilizes will correspond to the E/M code 99360. An emergency department patient requiring treatment of a potentially life-threatening condition and a high level of medical decision making will correspond to the E/M code 99285.

E/M coding is justified by clinical documentation noted in a patient’s chart/EHR. The documentation must mention the specific services rendered as well as the level of complexity for the interaction. Each CPT code has very specific guidelines to allow billing of that specific code, and the chart must contain these criteria to allow appropriate billing for the encounter. Furthermore, if a service was performed, but a physician or APC does not document the service, coding guidelines do not allow billing of the service.

Medical Decision Making (MDM)

Medical decision making (MDM) refers to the process clinicians use to make decisions and draw conclusions from any available medical data. There are many steps involved in a complete MDM process.

  1. The clinician interprets available patient data, including symptoms, test results, patient self-reporting, his or her own observations and anything else professionally relevant.
  2. The clinician may obtain or refer to previous medical records for relevant patient history or diagnoses, previous testing, or may compare current test results to previous results.
  3. The clinician considers a differential diagnosis, acknowledging all possible diagnoses which could explain the given medical data.
  4. The clinician eliminates certain differential diagnosis possibilities, settling on a diagnosis or concluding further investigation is needed to rule out multiple possibilities.
  5. Instructions for each diagnosis or possible diagnosis in order to provide the best possible care given the patient’s condition and relevant medical history.
  6. The clinician may discuss a case with a patient’s primary care physician or consultants.

The MDM process uses a number of skills clinicians acquire through every day practice and training in order to make an informed decision to produce the optimal outcome for a patient.

Medical billing often uses MDM to justify the use of certain coding levels. More complex situations, such as unknown conditions vs. known conditions or high-risk conditions vs. low-risk conditions, correlate with higher coding levels. To aid in this coding practice, an MDM complexity score may be applied using a rubric.

Medical Chart

A medical chart serves as a record of pertinent facts related to a patient’s medical care. Charts are intended to be comprehensive, encompassing the entirety of information available in the patient’s complete health record. A digital version of the chart often exists as an electronic health record (EHR).

Information documented in a chart often includes but is not limited to the following:

  • An initial/chief complaint and present symptoms
  • A review of systems, or associated questions pertinent to the chief complaint
  • A physical exam
  • Relevant medical history, including any prior diagnoses, ED visits, hospitalizations, surgeries or known medical conditions
  • Current medication lists and any relevant medications prescribed in the past, and any drug or other allergies
  • A narrative of past interactions with physicians and other healthcare providers, including the results of each visit or hospitalization
  • Results of diagnostic tests and imaging
  • Medical procedures, past and pending
  • Any diagnosis, differential diagnosis considerations, or other conclusions drawn by clinicians
  • A summary of the above thoughts and a plan of care, including any new or change in medications, follow up testing and appointments

Certificate of Insurance (COI)

Certificate of Insurance (COI) is a document used to provide information on specific insurance coverage. It provides verification of the insurance and usually contains the type of insurance, limits of coverage, the carrier name, policy number, name of insured and effective periods.

Hospital Credentialing and Privileging

Before hiring new medical professionals, hospitals must carry out credentialing, or a series of verifications, to ensure the applicant has the education, training, experience and licensure needed to properly practice at their facilities. Privileging a medical professional means giving them permission to practice medicine in a clinical capacity at the hospital. A physician must have privileges at a hospital to treat patients.

Clinical Decision Support (CDS)

According to HealthIT.gov clinical decision support (CDS) provides clinicians, team members, patients or other individuals with person-specific information, filtered or presented at appropriate times, to advance health and health care.

CDS encompasses a wide range of tools to enhance decision-making in the clinical workflow process. These tools include electronic alerts and reminders for physicians and other clinicians; clinical guidelines and best practices; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support; and relevant reference information and resources; and other tools.

Benefits of Clinical Decision Support 

  • Increase quality of care and improve outcomes
  • Decrease risk of errors and adverse events
  • Improve efficiency and patient satisfaction
  • Promote patient safety