In this example, a single encounter note is provided to support 2 separate claims. An easy option is to report the repair of the laceration to the automobile insurance and the evaluation and management (E/M) service to the health insurance plan. However, some elements of the history, examination, and medical decision-making were unrelated to the chief complaint of rash. It is necessary to determine the elements of service related to each of the presenting problems and report the appropriate codes to each payer.

Physicians and other qualified health care professionals (QHPs) must use clinical judgment in determining the elements of the E/M service that were medically necessary for each condition evaluated. Table 1 divides the E/M documentation elements by condition. (Opinions may vary on the reason for each element. This is only an example and does not represent a standard of care. Actual services may reflect other elements of service.)...

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