Documentation, general

Jun 2006 Issue
Improve Your ICD-9 Coding With Voice-Recognition Macros [Feature]

The author walks readers through the process of using macros to automatically insert correct ICD codes into their dictations, reducing staff time and increasing coding accuracy.

Feb 2006 Issue
Coding Level-IV Visits Without Fear [Feature]

The author describes the requirements for coding level-4 office visits.

Sep 2005 Issue
Make Medical Notes Better and Faster With Macros [Feature]

The author gives step-by-step instructions on how to record a macro, which can be used, he explains, to quickly and accurately document patient encounters, especially physical exams.

May 2005 Issue
How to Document and Bill Care Plan Oversight [Getting Paid]

This article will describe how to bill for and document care plan oversight, balancing it as a billing opportunity and a compliance risk. It will include a form for documenting CPO.

Jan 2005 Issue
A Sure Way to Improve Your Dictation [Improving Patient Care]

The article explains the merits of dictating notes in the exam room with the patient present, as a way to increase efficiency and improve patient care.

Oct 2004 Issue
A Tool For Evaluating Patients With Cold Symptoms [Improving Patient Care]

The article describes an encounter form that can improve documentation of visits for patients with cold symptoms and reduce the amount of time spent documenting, which sometimes can take longer than the visit itself.

Apr 2004 Issue
Making Sense of Preventive Medicine Coding [Feature]

This article explains what CPT's preventive medicine services codes are and how they should be used in family practice.

Mar 2004 Issue
A Tool for Evaluating Hypertension [Improving Patient Care]

The article offers an evidence-based approach to the diagnosis and treatment of hypertension, based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), and includes an encounter form to aid physicians in providing care consistent with the JNC 7 guidelines.

Feb 2004 Issue
How to Code for Observation Services [Getting Paid]

The author provides tips for coding and billing for complicated observation services, such as when an observation stay lasts more than one day or changes to inpatient status.

Oct 2003 Issue
Two Tried-and-True Documentation Tools [Feature]

The centerpiece of this article is the revised "Pocket Guide to the Documentation Guidelines" and the progress note template that originally appeared in January 1998. The article will include a brief introduction to the tools and a note for readers to analyze using the pocket guide.

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