Title: Record information from the encounter form, applying the appropriate codes for billing purposes and insurance claims.
Course: Medical Administration (14153-36) > Section: Maintaining Electronic Health Records and Files

Recording should include

- using American Medical Association’s Current Procedural Terminology (CPT)
- using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)
- adhering to office policies regarding the release of information.