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...]
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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...]
CMS update E/M documentation | Medical record documentation
CMS update E/M documentation | Reducing redundancy
CMS update E/M documentation | OIG EHR
Email Sign up – Definitive Guide to Documenting Time
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...]
Reference Sheet_Definitive Guide to Documenting Time_2021
Exam | Documentation Guidelines for E/M Services
This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202--99215 in 2021. Continue to use the 1995/1997 … [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
This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202--99215 in 2021. Definition History is … [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? 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...]
Documenting time for moderate sedation of 15 minutes
Question: When my doctor personally performs moderate sedation of 15 minutes, does he/she need to document the time in the … [Read more...]
Medical Decision Making | Documentation Guidelines for E/M Services
This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202--99215 in … [Read more...]
Definitive Guide to Documenting Time
Office visits, inpatient care, prolonged services, critical care...properly documenting time can help ensure that you receive the maximum allowable … [Read more...]
Coding Guide – Federally Qualified Health Centers
If you are looking for a guide to coding for FQHC visits, here it is. Clinicians in FQHCs use CPT and ICD-10 codes to select their services, but these … [Read more...]
Coding Guide – Teaching Physician Rules
The teaching physician rules are Medicare rules that allow for payment for services that are performed jointly between a resident and a licensed … [Read more...]
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