Coding to Documentation Requirements

As you document an encounter in a patient's EMR, PracticeStudio records the number of corresponding E/M code bullets (documentation requirements) that are being met.

Once the encounter has been documented, you can select the E/M Coding screen and review:

• The overall current level of service, as well as (or instead of)
• The level of service by specific categories.

The Complexity of Decision screen provides options to help further evaluate the level of service for billing purposes based on the complexity of your decision-making process.

You can then review the level of service that matches the current encounter documentation on the Documentation Guidelines screen, which helps you with the ability to code to exact documentation standards.