This HelpDesk Video lays out the concept of moving through documentation in reverse, from the treatment plan to the initial visit history. The value of this process cannot be overstated as this is an excellent way to ensure that you are establishing medical necessity for all the services you are billing and providing to the…
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Medicare’s Tx Plan Elements The purpose of a treatment plan in your documentation is to identify how you plan to restore the patient to pre-condition or full functional status. Medicare has very specific guidelines for what should be included in the documentation. KMC University recommends that providers follow these guidelines for all treatment plan documentation,…
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This Rapid Tutorial breaks up the expectations of a full treatment plan into an easy-to learn-format. As we come to the end of what is required in the documentation of an initial visit, examine this overview of the distinctly separate elements of a treatment plan. We expand upon the known elements of frequency and duration…
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Download Reference Documents The first two resources listed here are neck and low back diagnosis tables pulled, with permission, from the Sousa textbook. Refer to these tables to ensure your doctoring is leading to the most accurate diagnosis codes and that you have the findings to verify the codes you are using. In the third…
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Examples of Initial Assessments The following examples of initial assessments are provided for educational purposes only. A robust initial assessment sets the tone for the treatment episode. These samples include various prognostic factors and demonstrate how they can be incorporated into your initial visit documentation. The examples include language that supports the Medical Decision Making…
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Download Support Tool The terms and definitions given regarding medical decision making are crucial to understanding the new E/M coding guidelines. We recommend using the words found in this tool to establish your initial visit assessment in a way that leaves no question as to the appropriate level of E/M service that is being performed…
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