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…
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Medicare’s Documentation Requirements for Medical Necessity One of the most fundamental obligations in healthcare is proper medical record documentation. The Grandaddy of all requirements are those published by the Center for Medicare and Medicaid Services (CMS). Because there are few payers or state Boards of Examiners who have a stiffer requirement, mastery of Medicare’s documentation…
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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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