Coding Basics and Guidelines for Musculoskeletal Office Evaluation and Management. Issue 7 (July 2020)

• Record Type: Journal Article
• Authors: Hinckley, Nathaniel; Davidson, James; Henley, M. Bradford; Davidson, Jered R.; McIntyre, Louis; Chhabra, Anikar
• Is Part Of: JBJS reviews. Volume 8:Issue 7(2020)
• Publication Date: 2020-07
• Subjects: Bones -- Surgery -- Periodicals; Joints -- Surgery -- Periodicals; Orthopedics -- Periodicals; Orthopedics; General Surgery; Bone Diseases; Joint Diseases; Bones -- Surgery; Joints -- Surgery; Orthopedics; Periodicals; Electronic journals; Periodicals; 617.47
• DOI: 10.2106/JBJS.RVW.19.00194
• Languages: English
• ISSNs: 2329-9185

Abstract

Abstract : In documenting a patient encounter, the orthopaedic evaluation consists of 3 key components: "History, " "Physical Examination, " and "Medical Decision-Making." The level of service coded must be supported by the complexity of the problem, the care provided, and the documentation of the encounter. Determining whether the patient is new or established is the first step in the evaluation and management (E/M) process and relies on same-practice/same-specialty rules. Careful attention must be paid to documentation and coding to allow for appropriate care of the patient and efficient use of the orthopaedist's time. The available step-by-step guidelines include all necessary criteria to accomplish this. Continue to monitor for the U.S. Centers for Medicare & Medicaid Services (CMS) changes to stay up-to-date on changes in the guidelines.