Part 1: Discuss the difficulties that can occur if communication with patients isn’t clear.

The “use of medical jargon leads to poor communication between physicians and patients, and consequently leads to ineffective medical care”. Federal and state officials are now pushing healthcare professionals to use simpler language to communicate medical advice to patients. Each patient understands and learns things in different ways, you have to break down the complexities of medical science into something that that patient can understand, you have to modify your explanation depending on that patient. You can give them pamphlets, websites, and try to draw them a picture, and get a translator to help the patient to understand what you are trying …show more content…
Unsympathetic response to a patient's complaint.
Inadequate education (such as about medications).
Incomplete follow-up instructions.
No or wrong information given to patient.
Miss communication due to language barrier.

Part 2: Discuss the use of E/M codes and some common practice pitfalls that occur in the coding of E/M services.

Evaluation and Management (E/M) codes is the process by which physician-patient encounters are translated into five digit Current Procedural Terminology (CPT) codes to facilitate billing, these are the numeric codes which are submitted to insurers for payment. E/M codes must contain correct levels of History, Exam, and Medical Decision Making, levels depend on problem/problems presented.

Some common practice pitfalls that occur in the coding of E/M services.

The “most common error found for E/Ms is the lack of documentation to support the level of E/M Services billed”. Documentation lacks key components including Extent of History, Examination, and Complexity of Medical Decision Making (MDM).
Common Errors are:
Insufficient Documentation
Incorrect Coding
Medical Necessity Not Supported
Documentation Doesn't Support Level Billed
Prolonged Services
Time-based