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Medical record documentation is required to accurately record pertinent facts, findings, and observations
in regards to a patient’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes.
The medical record chronologically documents the care of the patient and the evaluation and management documentation of a service is a key part of the medical record.
Evaluation and management (E/M) services provide the nature and amount of physician work, and documentation varies by type of service, place of service, and the patient's status. Providers must ensure that medical record documentation supports the level of service reported to all payers.
For step-by-step instructions on documenting and coding the correct level of the E/M services, download the following resources for rheumatology practices.
Rheumatology Coding Manual
E/M Coding Chart
CMS Evaluation and Management Service Guide