Documenting Histories in E&M
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Documenting Histories in E&M (8 min • 10-2016)
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How to document the history component of Evaluation and Management services, and how that documentation relates to coding.
Related Articles
- Here are some related articles in Other Pediatric Practice Resources > Coding and Documentation:
How to Code for Immunizations and Administration
In January of 2011, immunization administration CPT codes changed. The administration w/ counseling codes that pediatricians used previously (90465-90468) became invalid for billing. Two new codes (90460 and 90461) replaced them, and the replacement includes a change in the coding method, from per-shot to per-antigen.- On October 1, 2015, insurance payers will stop accepting ICD-9 diagnosis codes for most claims and require ICD-10. How can your practice prepare for the ICD-10 transition?
Diagnostic Code Sets (SNOMED-CT, ICD-10, ICD-9) in PCC’s Software and Services
How are SNOMED-CT and ICD-10 used in PCC's products and services? Where will you see each taxonomy, and will you still see ICD-9 in your patient records? This article provides a basic overview of how these different code sets appear in PCC.CPT II in PCC’s Partner Billing System
Partner supports the American Medical Association's CPT II code specification, a subset of the standard CPT codes used for procedures.PCC’s Pediatric Practice Management, Billing, and Coding Web Labs
Jan Blanchard, PCC’s certified pediatric coder, offers monthly coding web labs to all PCC clients. She covers how to code for both simple and unusual visit types, how to handle the differences between ICD-10 and SNOMED-CT descriptions, and how to configure PCC’s software products to best meet the coding needs of your busy office.New Patient vs Established Patient E&M Services
PCC's Jan Blanchard explains the importance of accurate documentation of established patient vs. new patient Evaluation and Management services.Documenting Physical Exam in E&M
How to document the physical exam component of Evaluation and Management services, and how that documentation relates to coding.Judgment Calls in E&M Leveling
Guidance about making E&M leveling judgment calls, specifically between 99213 and 99214.- Use the information from our previous E&M videos to level a visit.
- E&M services make up the bulk of the work you do as a pediatrician. PCC has educational content, tips and videos you can use to master E&M and improve your coding workflow.