Documentation & Coding Archives

Distinguish Between an 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.

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Incident, Burst, or Episode

Download Reference Document The terms incident, burst and full episode were coined by us here at KMC University as a way for providers to consider and clearly define the length of an episode of care. When sitting down to document the initial visit of a new episode, consideration of the potential length of the episode…

Medically Appropriate History and/or Examination Defined

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…

Proper Use of Evaluation and Management (E/M) Codes in a Chiropractic Office

Knowledge is Power for E/M Coding and Documentation Knowledge is power when it comes to E/M coding and documentation. A working knowledge of E/M coding is the best way to ensure optimal compliance and to avoid inadvertently under- or over-coding when describing evaluation and management. Physicians that understand the idiosyncratic process of E/M coding documentation…

Gain a Solid Command of Initial Visit Documentation Requirements

This Rapid Tutorial sets the tone for this module, but also for the entire course focused on Documentation of Evaluation and Management. Start your training by better understanding what an initial office visit looks like in the context of your documentation. Often, providers forget when dealing with an insured patient, that the initial visit of…

Medicare’s Signature Guidelines Reference Documents

Download Reference Documents Medicare publishes helpful documents and alerts to keep providers in the know about important topics. Included here are several documents that relate specifically to the rules of properly signing the medical record notes of patients. These tools relate to the elements of signatures, authentication, and attestation, should that be necessary. We’ve also…

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