Thank You, And. And thank you everyone for attending today's webinar on the fundamentals of exam auditing. So today, you'll learn the tools needed for audit evaluation and management services.
You'll also master the documentation guidelines for these services while receiving a breakdown of the differences between 1995 and 1997 guidelines we'll, discuss the fine line and documentation guidelines and also evaluate examples of evaluation and management cases. So we'll get started. So there are seven. Components of an E&M code, um, the three key components are what most of us focus on.
And these include the history physical examination and the medical decision-making next. You have your other contributing factors, such as time counseling coordination of care and the nature of presenting problems or your chief complaint. So here are a few examples of what a chief complaint could look like so here's. The first example we have a 52-year-old male present today with severe abdominal pain, a 76-year-old. Female presents today for a screening colonoscopy and an 80-year-old female presents with asthma HERD and shortness of breath.
So it is not sufficient documentation for a sheep complaint to only list follow-up. And I know, we all see that a lot on our documentation, but it's, not sufficient documentation. So in documenting history, the chief complaint requires the reason for the encounter the history of present illness is description of the patient's illness or injury. The review of systems is answers.
To the questions related to the body systems and your Pia SH are the past medical family and social history let's start with HP or history of present illness. All the history of present illness must be documented by the provider. Now there are eight elements of HP. And here are examples of each location could be cervical pain quality could be pressure, stabbing, dull, itchy severity could be worsening intractable nine on a scale of one to ten duration. The pain start at four days ago, timing during.
Sleep comes and goes context. The patient fell down the steps or was injured running in a marathon, modifying factors ice and heat did not help over-the-counter medications were taken and associated signs and symptoms chest pain. Nausea vomiting. You.
Dated : 18-Apr-2022