Welcome to the June Compliance Blog Post!
We are back with a Compliance Blog Post for June 2023. This month we are giving you a Peek Behind the Medical Coding Curtain and talking about Evaluation and Management visits.
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What is Medical Coding?
Medical coding is the task of assigning standardized diagnosis and procedure codes to a patient visit to accurately describe the patient’s condition, their treatment, and anything else done during the visit such as small procedures, lab tests, or vaccinations. The most common “codes” HealthPoint uses are for the office visit itself, using Evaluation and Management (E&M) codes. Almost every patient visit at HealthPoint has an E&M service, where the provider speaks with the patient and makes decisions on how to diagnose/treat the patient.
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Can you explain more about E&M Visits?
The correct E&M code to use varies based on the medical complexity of a patient, which can be described by the providers’ level of “Medical Decision Making”, or MDM, during the visit. The MDM level for a visit can be found by asking two questions: “What is the risk that the patient’s condition will threaten their life or bodily function if left untreated?” and “What is the risk that the treatment of this condition will threaten their life or bodily function?”. The higher the level of risk involved in the patient visit, the higher the MDM level, and the higher the level of E&M service assigned to the visit.
That is a lot to remember. Do you have a “cheat sheet”?
Some of our providers use the following card to find the correct E&M code quickly. The E&M codes are in green and organized by the level of MDM: minimal risk, low risk, moderate risk, and high risk. Below each section are a few examples of types of injuries/illnesses in each risk category and their treatments.
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E&M Coding Card Front:
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E&M Coding Card Back:
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We are Here to Help!
If you have any questions about any of these, please feel free to reach out to our Medical Coder, Lena Sadler, via Teams and/or email at LenaSadler@healthpoint-tx.com
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