FPM Toolbox

Coding and Documentation

Chart Review Form

A form used to evaluate progress notes to determine whether the documentation supports the coding
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Checklist of Care Plan Oversight Requirements

A checklist to determine if you have a situation that meets the physician and beneficiary requirements for CPO
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Decision Tree for New and Established Patients

A decision tree for determining whether a patient is new or established
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Documentation Requirements for Established Patient Office Visits

A table that shows the history, exam and medical decision making requirements for each of the established patient office visit codes
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Documentation Requirements for New- and Established-Patient Office Visits

A table that shows the documentation requirements for new and established patient office visits
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Documenting Diabetes Mellitus Under ICD-10

A two-page document listing the ICD-10 codes for diabetes mellitus and explaining the steps involved in documenting these codes.
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Documenting History at a Glance

A set of tables that show the requirements for documenting the history component for both new and established patient office visits.
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Established Patient Level-IV (99214) Visit Worksheet

A quick reference for identifying the criteria for documenting a 99214 established patient visit; based on the 1995 guidelines
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Evaluation and Management Guidelines at a Glance

A two-page summary of the documentation guidelines for E/M services
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Face-to-Face Transitional Care Visit Documentation

A template to help physicians record details of the face-to-face visit portion of a transitional care service
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General Multisystem Examination

A one-pager outlining the documentation requirements for general multisystem exams
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Initial Transitional Care Contact Form

A form for documenting the initial contact a practice has with a patient receiving transitional care services
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Integrated Summary Template

A one-page template that summarizes the patient's health by including a problem list, medication list, past medical history, flow-sheet parameters, etc.
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Nursing Home Documentation Form

A one-page form that standardizes and simplifies clinician documentation of nursing home care
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