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Evaluation and Management Services
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Allergies altered anesthesia assessment and plan audit avoid billing chief complaint clinical complicated consent forms consultation cosurgeons cough CPT codes Current Procedural Terminology detail diagnostic tests dictation documentation practices E/M codes E/M service encounter form entry Evaluation and Management exam example expanded problem focused findings guidelines HCPCS healthcare healthcare provider hospital ICD-9 codes indicate informed consent internist interventional radiology involved key component laboratory lesions level of service medical decision medical history medical malpractice medical necessity medical problems medical record medical services medical visit Medicare Medicode nonphysician operative report patient chart patient encounter patient information patient record patient's medical record performed physical examination Physician Signature postoperative private payers professional liability claim radiological exam radiologist reference reimbursement requesting physician require rhonchi risks and benefits second physician signed SOAP format specific specimen summary surgery surgical procedure transcription usually written consent x-ray