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The Five Step Process for E&M Billing

  1. Determine the service that is medically necessary.
  2. Provide the service needed in order to properly meet the patient's needs.
  3. Document the service provided.
  4. Select the most appropriate Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code for the service needed medically, provided and properly documented.
  5. Submit the service to Medicare that was medically necessary and documented.

CHECK YOUR RECORDS FOR THE FOLLOWING...

  • Records are legible; all abbreviations and symbols will be easily recognized by reasonable clinicians.
  • The patient's name and the date of service appear on every page of the record (including the back side of double sided forms).
  • The date of service on the record matches the date of service in the claim.
  • The identity and professional credentials of all persons who contributed to the service and/or the record clearly indicate which portion(s) of the service and/or record was contributed by whom.
  • Information in the record clearly supports all diagnoses reported on the claim.
  • Information in the record clearly demonstrates all of the work described by the code(s) and/or modifiers reported on the claim were performed.
  • All procedures reported are clearly documented
  • Evaluation and Management (E/M) services reported on the same day as a procedure are clearly documented, medically necessary, significant and separate from the procedure.
  • The record of services performed "incident to" a physician service demonstrates the link between the employee's work and the physician's service.
  • The record of services split/shared by a physician and non-physician practitioner demonstrates the face-to-face encounter and contribution to patient management by each practitioner involved.

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