Download Reference Documents These Reference Documents are helpful tools as you continue to get familiar with and follow the rules of documentation of initial visits. First, you’ll find the official document from the American Medical Association (AMA) laying out the new 2021 Evaluation and Management (E/M) updated guidelines for coding your E/M services. This document…

Download Documentation Samples These documentation samples are provided not only as an example of the necessary components of a note, but also to indicate in the sidebar the reasoning for the individual pieces needed to create the best possible note to document and relay the information essential for various patient case types. Notice that the…

Download Reference Document Download, review and use this extremely helpful tool that outlines Medicare’s requirements and explanations for documenting the initial evaluation and management note and the daily visit note. Save this tool and use it to guide you as you strive to create compliant documentation, especially when lacking any other guidance from third party…

Using Clinical Judgement Medicare requires that medical necessity be proven using the components of PART: Pain, Asymmetry, Range of motion, and Tissue tone changes. Two of these four elements must be present, and one must be Asymmetry or Range of motion. These are findings that are usually discovered during the initial evaluation of the patient…

Distinguish Between and Initial and Routine Office Visit This brief overview further solidifies the distinction between these two basic formats of your documentation. As you review this, consider your own documentation style, and confirm that there is a difference that clearly distinguishes between initial and routine office visits.