This Rapid Tutorial sets the tone for this module and for the entire course focused on Documentation of Evaluation and Management. Start your training by better understanding what a routine office visit looks like in the context of your documentation. Often, providers forget the ROV within “episodic care” must have a minimum set of targeted…
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In the world of documenting an episode of care, the end of the episode is just as important as the beginning. As you have seen previously in this module, laying out a sound initial visit note sets the stage for compliant documentation through the entire episode, leading into the progress exams, and eventually to the…
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Download Reference Documents The reference documents for this module encompass multiple practice guidelines, definitions, and documentation requirements. Please note that some of these resources are in other courses in this module as they have relevance to more than one aspect of the various parts of documenting an initial visit note, periodic re-evaluation, and discharge exam….
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Potential Criteria Calling for Medically Necessary X-Rays You must have a specific reason to expose a patient to ionizing radiation to visualize his/her spine and meet the criteria of medical necessity. “I want to see what I am adjusting” is no longer a sufficient reason to take X-rays and ask a third-party payer to reimburse…
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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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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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