ITEMS IN FPM ON TOPIC:
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.
The author describes the requirements for coding level-4 office visits.
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.
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.
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.
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.
This article explains what CPT's preventive medicine services codes are and how they should be used in family practice.
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.
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.
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.