(Optional) Record information from the encounter form, applying the appropriate codes for billing purposes and insurance claims.

Recording should include

• using American Medical Association’s Current Procedural Terminology (CPT) Links to an external site.
• using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Links to an external site.
• using medical terminology
• entering data into medical records manually and electronically
• adhering to office policies regarding the release of information.