Document MDM The new Evaluation and Management (E/M) coding rules that went into effect at the beginning of 2021 led to many questions that require clarification on what documentation should look like, as the coding is now based on Medical Decision Making (MDM) or Time. One of the main reasons for the change to this…
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No Two Patients are Alike Each has a multitude of factors that make up who they are, both inside and outside the office. When treating patients, we need to consider these variables in relation to how each patient responds to treatment and what modifications may be necessary to accommodate his/her unique situation. Additionally, these co-morbidities,…
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Written Diagnosis vs ICD-10 Coding In the typical Evaluation and Management (E/M) service, providers document the patient’s history, quantify that history with an examination, and from those cornerstones, derive the assessment, diagnosis, and treatment plan. This is recorded in the patient’s health record and using this information, both Current Procedural Terminology (CPT®) and International Classification…
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The Clinical Dx Process Chiropractors often confuse a diagnosis with the assessment portion of an initial visit note. The diagnosis and the treatment plan are just components of the assessment. The assessment, coupled with the information gathered while taking the patient’s history during examination, and his/her working diagnosis, reveals more about the patient than the…
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This Rapid Tutorial takes you through the clinical diagnosis process from collecting patient information, to data gathering and physical findings, to the written clinical diagnosis that is required in the assessment. Watch this video as you continue to learn how to connect all notes to those of the initial visit to clearly establish medical necessity…
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Initial Note: Where Everything Comes Together Assessments are what separate physicians from technicians. The assessment portion of the initial note is where everything comes together. Despite common belief, the assessment is not simply the diagnosis and treatment plan, although both do play a role in its formation. It is much more than that. The assessment…
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