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Evaluation and Management (E/M) refers to a set of guidelines utilized by healthcare providers to document and bill for patient encounters. It encompasses the assessment, diagnosis, and treatment of patients, helping determine the level of care provided.
Healthcare providers who offer evaluation and management services, such as physicians, nurse practitioners, and other clinicians, are required to file E/M documentation for billing and reimbursement purposes.
To fill out an E/M form, providers must document patient encounters by including details such as the patient's history, examination findings, medical decision-making, and the level of service rendered, following appropriate coding guidelines.
The purpose of E/M is to standardize the documentation and billing of healthcare services, ensuring that providers are reimbursed appropriately for the complexity and time involved in patient care.
The information that must be reported includes the patient's chief complaint, history, physical examination findings, medical decision-making details, and the level of service provided, all of which support the coding for reimbursement.
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