Documentation, general

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.

Sep 2003 Issue
Understanding When to Use the New Patient E/M Codes [Feature]

The author explains the CPT definition of "new patient" and describes how to document and code new-patient visits in compliance with Medicare's "Documentation Guidelines for Evaluation and Management (E/M) Services."

Jul-Aug 2003 Issue
Encounter Forms for Better Preventive Visits [Feature]

The author describes and provides two preventive visit documentation and reminder tools – one for male patients and one for female patients.

Jun 2003 Issue
Time Is of the Essence: Coding on the Basis of Time for Physician Services [Feature]

The article explains how a physician's time spent providing a service can influence the level of coding in certain situations.

May 2003 Issue
An Update on the E/M Codes and Documentation Guidelines [Getting Paid]

The author explains recent developments surrounding the revision of the documentation guidelines for evaluation and management services.

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