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Chapter Highlights

  • General and specific evaluation and management (E/M) guidelines

  • Concepts of new versus established patient and initial versus subsequent encounter

  • Reporting single or multiple services when provided in the same setting or in 2 settings with different designations (eg, hospital and nursing facility)

  • Current Procedural Terminology (CPT®) terms and definitions used in determining a level of E/M services based on a physician’s or other qualified health care professional’s (QHP’s) total time on the date of an encounter or on medical decision-making (MDM)

  • The Centers for Medicare & Medicaid Services (CMS) guidelines for reporting services provided as a teaching physician, when applicable

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