The Clinical and Written DX Process
In the typical Evaluation and Management (E/M) service, providers document the patient’s history, quantify that history with an examination, and from those cornerstones, derive the assessment, diagnosis, and treatment plan. Although most Electronic Health Record (EHR) software is programmed to list the diagnosis in written form and the ICD-10 code, the written diagnosis determines the appropriate ICD-10 code or codes that are assigned. Our members enjoy one hour of continuing education credit (in participating states)…