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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.
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