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Evaluation and Management (E/M)

Explain what pertinent information, generally, is required in documentation to support DSM-5 and ICD-10 coding. Ex​‌‍‍‍‌‍‍‌‍‌‌‍‍‍‌‍‌‌‌‍​plain what pertinent documentation is missing from the case scenario, and what other information would be helpful to narrow your coding and billing options. Finally, explain how to improve documentation to support coding and billing for maximum reimbursement.