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Carson Lemon:
Your detailed explanation of E/M coding sheds light on important issues in clinical
documentation and patient treatment. Care for patients and the subsequent assignment of E/M
codes based on characteristics such as location, service type, and health condition should be
subject to close inspection. Regarding healthcare billing, reimbursement, and audit readiness,
the adage “If it is not documented, it didn’t happen” rings particularly true, not only for ethical
and legal reasons. Your point that the CMS principles have helped create some semblance of
uniformity in this complex coding scheme is one I share. When it comes to protecting against
inaccurate invoicing and violations of compliance, CMS requirements are more than just
simple to follow. In addition to the medical history and physical exam, the Medical DecisionMaking (MDM) component increases the need for accuracy in E/M coding.
You’ve given us an excellent foundation for comprehending the degree of individualization
necessary in medical assessment with your hypothetical scenario with two patients with
pneumonia symptoms but differing medical histories. It’s a graphic illustration of the time
pressures …
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