04/02/2019

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On-Demand Training: Evaluation and Management (E/M) Services

Evaluation and Management (E/M) - History Component
This course explains the history component of an evaluation and management (E/M) service. The medical record requires the chief complaint, the history of present illness, the review of systems, and the past, family, and social history. Complete documentation is needed in the medical record to support the medical necessity of the service, the procedure code chosen, and the medical necessity of that level of service. Full details are on the WPS GHA Learning Center.
 
Evaluation and Management (E/M) - Exam Component
This course explains that the exam component of an evaluation and management (E/M) service has two distinct ways of documenting the services; either the 1995 or the 1997 Documentation Guidelines can be used. During this presentation, WPS GHA staff discusses the differences and the ways to evaluate the documentation to support the level of service submitted and the medical necessity for the service. Full details are on the WPS GHA Learning Center.
 
Evaluation and Management (E/M) - Medical Decision-Making Component
During this course, WPS GHA discusses the three separate components of medical decision-making (MDM): diagnosis and/or management options, amount and/or complexity of date to be reviewed, and risk for the patient. Documentation is necessary in the medical record to show the medical necessity of the service, the procedure code chosen, and the medical necessity of that level of service. Full details are on the WPS GHA Learning Center.
 
Evaluation and Management (E/M) - Things to Think About
What are some other things to think about when looking at Evaluation and Management (E/M) billing and documentation? This course discusses medical necessity, the use of your electronic medical record, things to look for (abbreviations, testing, and audits) and more. Full details are on the WPS GHA Learning Center.
 
Evaluation and Management (E/M) - Documentation Examples
The medical record is vital in determining the medical necessity and coding of an evaluation and management (E/M) service. During this course, WPS GHA explores two pieces of documentation, looking for the individual elements of an E/M service: the history, exam, and medical decision-making. We will discuss both the positive and negative aspects of the documentation. Full details are on the WPS GHA Learning Center.