Defining Medically Appropriate History and/or Examination With the release of the new Evaluation and Management (E/M) Guidelines in 2021, gone are the days of determining the E/M code by counting bullets in an examination and levels in a history. The new guidelines indicate that coding is established based on either the level of Medical Decision…
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This Rapid Tutorial lays out the patient chart flow through an office, zeroing in on the importance of a medically appropriate history as well as reviewing different guidelines and what is expected when looking at an initial visit history in the documentation. Begin to build your training by learning how to obtain and document an…
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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…
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Download Reference Documents 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…
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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…
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Using Clinical Judgement to Document PART 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…
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