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BASICS of E/M CODING

BASICS of E/M CODING ASSIGNING THE CORRECT E/M CODE TO YOUR CLAIMS A HANDBOOK FOR PHYSICIAN OFFICES August 2009 THE PURPOSE of this HANDBOOK (What it is & What it is not) MSSNY and the county medical societies of New York State are constantly seeking ways to bring value to our members. This handbook is to be used as a resource by office staff tasked with billing and claims submissions. Our hope is that it will help offices operate more efficiently and effectively. While this is no substitute for formal and extended training in E/M CODING and claims submission, The BASICS of E/M CODING Handbook gives essentials and offers resources for reference and further information. This 2009 edition is a first effort, and no doubt suggestions for additions and changes will be incorporated in subsequent editions.

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. 7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.ii

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