Evaluation/Management (CPT)

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EVALUATION/ MANAGEMENT (CPT) Name Professor Institution Course Date Evaluation/ Management (CPT) In the medical profession coding is the clinical improvement made to present a doctor’s diagnosis and determine medical necessity. Once understood the process of coding is not as complicated as it seems. Codes are divided into section, subsection, subheading and category. This arrangement makes it easier to locate different codes and items in the different manuals available. It is also helpful in making claims when a third party payer is involved. Thus the process of coding is paramount to any person it is associated with CITATION Deb09 l 1033 (Eid, 2009). In the evaluation and management system coding is very important. The documentation involved in this section may include chief complaints. This is a brief statement by the patient describing the purpose or the need of the encounter. There is also the History of Present illness. This is a description, in a sequential order, of how the patient’s symptoms started off. It may include the location, severity, and quality of a symptom. The other documentation is time. For this, the amount of face and non-face to face time a physician spends with a patient is recorded. Mostly the excess time a patient and a physician spend together is what is recorded. For success when coding evaluation and management sections the coder must exert utmost concentration. For instance, when coding time, the correct codes must be used to describe the exact time. Type of code should also be taken into consideration. For instance, an unlisted code should never be submitted without a special report CITATION Deb09 l 1033 (Eid, 2009). A

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