In 2024, CPT expanded its definition of split/shared services, CMS updated their requirements. CPT expanded its definition of split/shared … [Read more...]
Search Results for: document
Documentation for Advance Care Planning
Question:Â How much detail do I need to include in documentation for Advance Care Planning? Answer: Document the discussion in enough detail that … [Read more...]
Does a Practitioner Need to Document Time for a Telehealth Visit?
Question:Â Does a practitioner need to document time for a telehealth visit? What if it is audio only? Answer: First: For a telehealth visit, … [Read more...]
Essential Documentation for Medication Management and Psychotherapy
When providing both medication management and psychotherapy, practitioners need to document the time spent in psychotherapy and describe the therapy. … [Read more...]
Documentation Essentials for Codes 99202—99215
The AMA developed new guidelines for office visits in 2021, and then revised them in March, 2021. (That was fast). Are you confident that you are … [Read more...]
Documenting and Coding Observation Services in 2021
For Medicare patients in observation, the consulting physician uses new and established patient visit codes. Only the admitting physician can use … [Read more...]
APRN and PA Students and Medical Record Documentation
Question We have students from a nurse practitioner program rotate through our practice. Can we use their notes the same way as medical student … [Read more...]
Medical Record Documentation | Webinar
Medical Record Documentation: CMS reducing the burden Recorded April 23, 2020 CMS wants to ease the burden of physician documentation of E/M … [Read more...]
CMS Update on Medical Record Documentation for E/M Services
The world as we knew it Both the 1995 and 1997 evaluation and management (E/M) documentation guidelines stated that ancillary staff could record a … [Read more...]
Exam and Time in a Visit | Documentation Requirements in E/M Services
Question: For an established patient, if I don’t document a physical exam, am I required to say that the visit was a counseling visit and document … [Read more...]
Exam | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong....) However, we will still need to use them when auditing … [Read more...]
Are Changes Coming to the E/M Documentation Guidelines?
Do you remember that CMS is talking about changing the documentation requirements for E/M services? If it slipped your mind in the course of your … [Read more...]
History | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong....) However, we will still need to use them when auditing … [Read more...]
Psychotherapy Documentation Guidelines | Time
Question: Is it okay to use the time description in the order as the documentation of the psychotherapy time? Â The therapist selects 90832, … [Read more...]
Documenting Exam | Evaluation and Management Services
Lunch and Learn Exam is the second key component of evaluation and management services. This short video discusses the requirements for documenting … [Read more...]
Documenting History | Evaluation and Management Services
Lunch and Learn What does a clinician need to document in the history? Is it okay to say, "non-contributory"? What if the medical assistant takes … [Read more...]
Meatloaf Says, “2 Out of 3 Ain’t Bad” | E/M Documentation Guidelines
Question: When selecting an E/M service for an established patient, does medical decision making need to be one of the determining … [Read more...]
Medical Decision Making | Documentation Guidelines for E/M Services
ARCHIVE The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong....) However, we will still need to use them when auditing … [Read more...]
Definitive Guide to Documenting Time
This is an E/M reference using the 1995/1997 guidelines. As of Jan 1, 2023 it will no longer be in use. Why have we kept it on the site? In case you … [Read more...]
Remote Therapeutic Monitoring
There are six remote therapeutic monitoring codes in the general medicine section of CPT® which may be performed by physicians, PAs and NPs and other … [Read more...]
Blood Pressure Self-Measurement: Education, Training and Analysis | CPT Codes 99473, 99474
There are two CPT codes specifically for blood pressure self-measurement and management. The first is for patient education and calibration of a home … [Read more...]
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