Please post a 3-page initial response to the following (A title page is not required and please paste your initial discussion directly into your posting).
Consider the statement: If it is not documented, it did not happen from the standpoint of making a claim for services rendered. How is this relevant to the issue of coding E/M procedures and services? [Tips: Coding is limited to the documentation in the patient’s medical record. The medical record is the documentation that supports a claim. If that record is incomplete, the claim is not supportable. Consider the highest levels of E/M services, patient histories and examinations and complex MDM to diagnose and treat the presenting condition].What are some of the advantages of using the CMS guidelines for E/M coding? The assignment of codes from the E/M section is determined by three factors. What are the three factors? [Tip: there are three types of service included in the E/M section]. Why are these factors [Tip: three types of service] important in coding procedures and services in this section?
Two patients present with similar symptoms. Both appear to be suffering from pneumonia. One patient is a 55-year-old woman with controlled hypertension and diabetes; the other is an otherwise healthy 24-year-old woman. How would the examination levels differ for the two patients? [Tip: think about patients in regards to dealing with histories, examinations, multiple comorbidities, and levels of complexity MDM (low-complexity, moderate-complexity, and high-complexity MDM)].
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