ITEMS IN FPM ON TOPIC:
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.
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."
The author describes and provides two preventive visit documentation and reminder tools – one for male patients and one for female patients.
The article explains how a physician's time spent providing a service can influence the level of coding in certain situations.
The author explains recent developments surrounding the revision of the documentation guidelines for evaluation and management services.