CHAPTER 1

Introduction

Centers for Medicare & Medicaid Services (CMS) provides coders, physicians, and claim reviewers with guidance on acceptable documentation standards for Evaluation and Management (E/M) services. E/M codes were included in the Current Procedural Terminology (CPT) code book in 1992. These codes were designed to classify services provided by physicians during office and hospital visits, skilled nursing facility visits, and consultations. The various levels of the E/M codes describe the amount of effort, time, responsibility, medical knowledge, and decision making that physicians contribute to the prevention, diagnosis, and treatment of medical illness and injuries. Health care facilities, such as hospitals, also report E/M ...

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