- Verify the patient’s medical history and document any changes or updates.
- Perform a comprehensive evaluation of the patient, including a review of their medical history, physical exam, and any necessary diagnostic tests.
- Determine the appropriate level of service based on the complexity and severity of the patient’s condition.
- Document all services provided to the patient, including any diagnosis, treatment, and procedures performed.
- Ensure that all services are coded accurately using the appropriate CPT codes.
- Use modifiers appropriately to ensure accurate reimbursement.
- Communicate effectively with other healthcare providers involved in the patient’s care.
- Review medical claims for accuracy and completeness before submitting them to insurance companies.
- Stay up-to-date on changes in coding guidelines and regulations that may impact E/M coding practices.
- Maintain accurate records of all E/M coding activities and transactions.
