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The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.
HCPCS includes three levels of codes: Level I consists of the American Medical Association's Current Procedural Terminology (CPT) and is numeric.; Level II codes are alphanumeric and primarily include non-physician services such as ambulance services and prosthetic devices, and represent items and supplies and non-physician services, not covered by CPT-4 codes (Level I).
Evaluation and management coding (commonly known as E/M coding or E&M coding) is a medical coding process in support of medical billing.Practicing health care providers in the United States must use E/M coding to be reimbursed by Medicare, Medicaid programs, or private insurance for patient encounters.
Capture patient care data using a standardized coded nursing terminology. Code electronic clinical encounters: diagnoses, interventions, and outcomes. Track nurses' contribution to patient care and care outcomes. Provide standardized concepts (data/elements) for clinical pathways and decision support.
The ordering process includes a display of the patient's medical history and current results and evidence-based clinical guidelines to support treatment decisions. Often uses medical logic module and/or Arden syntax to facilitate fully integrated Clinical Decision Support Systems (CDSS). Patient safety features The CPOE system allows real-time ...
Conducting an independent medical examination does not establish a typical doctor/therapist-patient relationship as exists when a clinician treats a patient in the hospital or at an outpatient clinic. However, the independent, objective (unbiased) nature of the examination does not absolve the doctor from all professional responsibilities.
Procedure codes are a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The structure of the codes will depend on the classification; for example some use a numerical system, others alphanumeric.
Progress Notes are the part of a medical record where healthcare professionals record details to document a patient's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review. Progress ...