Documentation, general

May/June 2010 Issue
Exam Documentation: Charting Within the Guidelines [Feature]

The article, the second in a three-part series, details the section of Medicare's E/M documentation guidelines pertaining to exams and explains how to comply and practice efficiently with them.

March/April 2010 Issue
Documenting History in Compliance With Medicare's Guidelines [Feature]

The author details Medicare's guidelines for documenting the history portion of E/M visits. Medicare and many private payers use the guidelines to determine whether physicians' documentation supports the level of service they code.

January/February 2010 Issue
Tools and Strategies for Improving Asthma Management [Feature]

The article describes the quality-improvement tools and strategies the authors used to increase adherence to evidence-based guidelines and improve asthma care in their family medicine clinic.

January/February 2010 Issue
The Physician Quality Reporting Initiative: Secrets to Success [Feature]

This article shares one practice's success story with the Physician Quality Reporting Initiative (PQRI) and provides readers with experienced advice and tips on reporting successfully.

Mar-Apr 2009 Issue
Chart Audit: Is Your Practice Billing What It Should? [Feature]

The author presents a simple and practical method for performing effective and efficient chart audits to determine whether the practice is coding services accurately and documenting them completely.

Jan-Feb 2009 Issue
Charting Then and Now [The Last Word]

Chart notes used to be primarily for doctors, but oh how times have changed.

Nov-Dec 2008 Issue
Coding From the Bottom Up [Feature]

Outlines an approach to CPT coding for common evaluation and management services that works from medical decision making "backwards" to physical exam and history.

Nov-Dec 2008 Issue
Time Is on Your Side: Coding on the Basis of Time [Feature]

The author, a well-known coding consultant, explains the rules governing CPT coding for evaluation and management services in cases where it makes sense to code on the basis of visit length rather than elements of the history, physical exam, and clinical decision making.

Apr 2008 Issue
What You Need to Know When Called Upon to Be a Good Samaritan [Feature]

The authors describe how to respond to roadside and in-flight emergencies and address legal issues that may arise.

May 2007 Issue
Avoiding Ambiguous Documentation [The Last Word]

Unclear terms can weaken medical documentation and confuse your colleagues, and this physician has had enough.

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