ITEMS IN FPM ON TOPIC:
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.
The article explores how simple interventions can save physicians time. For example, the author has improved the efficiency of her practice's lab reporting process by using standard stamped messages in place of writing those messages by hand.
The author presents his "integrated summary," a paper-based documentation tool that captures the patient's most crucial data on a single page, and explains how it can assist physicians in providing high-quality, efficient care.
This article discusses the basics of CPT coding for office and hospital visits, giving special attention to the codes family physicians use most (established-patient office visit codes).
This article will test the readers' coding knowledge by asking them to code a number of sample progress notes in the first half of the article and then compare their codes with those recommended by a panel of coding reviewers in the second half of the article.
Argues that E/M coding is fundamentally unworkable as a way of determining charges because it functions in a system where incentives are not aligned.