FPM Toolbox
Coding and Documentation
Download tools to help you understand coding and documentation requirements for new and established patient visits.
A Starter List of EHR Macros |
| A spreadsheet of macro ideas to ease documentation |
| Download Format: Excel |
| Source Article |
Chart Review Form |
| A form used to evaluate progress notes to determine whether the documentation supports the coding |
| Download Format: PDF |
| Source Article |
CPT E/M Office Revisions Level of Medical Decision Making |
| The official medical decision making table from the American Medical Association |
| Tool as published |
| Source Article |
Decision Tree for New and Established Patients |
| A decision tree for determining whether a patient is new or established |
| Download Format: PDF |
| Source Article |
DME Documentation Templates |
| Templates for documenting medical necessity of certain types of durable medical equipment |
| Download Format: PDF |
| Source Article |
DME Ordering Templates |
| Templates for ordering certain types of durable medical equipment |
| Download Format: PDF |
| Source Article |
Documentation Requirements for New- and Established-Patient Office Visits |
| A table that shows the documentation requirements for new and established patient office visits |
| Download Format: PDF |
| Source Article |
Documenting Diabetes Mellitus Under ICD-10 |
| A two-page document listing the ICD-10 codes for diabetes mellitus and explaining the steps involved in documenting these codes. |
| Download Format: PDF |
| Source Article |
Documenting History at a Glance |
| A set of tables that show the requirements for documenting the history component for both new and established patient office visits. |
| Download Format: PDF |
| Source Article |
Evaluation and Management Guidelines at a Glance |
| A two-page summary of the documentation guidelines for E/M services |
| Download Format: PDF |
| Source Article |
Face-to-Face Transitional Care Visit Documentation |
| A template to help physicians record details of the face-to-face visit portion of a transitional care service |
| Download Format: PDF |
| Source Article |
FPM Superbill |
| A superbill to capture the codes most common in office-based outpatient practice |
| Download Format: Excel |
| Source Article |
ICD-10: HCC Coding Reference for Family Medicine |
| A coding reference tool listing common diagnoses and the HCC weight for each one |
| Download Format: PDF |
| Source Article |
Initial Transitional Care Contact Form |
| A form for documenting the initial contact a practice has with a patient receiving transitional care services |
| Download Format: PDF |
| Source Article |
Medicare Superbill |
| A superbill to capture the CPT and HCPCS codes most commonly used in office visits with Medicare patients |
| Download Format: Excel |
| Source Article |
Nursing Home Documentation Form |
| A one-page form that standardizes and simplifies clinician documentation of nursing home care |
| Download Format: PDF |
| Source Article |
The Rosetta Stone four-step template for coding office visits |
| Four steps to coding E/M office visits using the new guidelines without counting data points |
| Download Format: PDF |
| Source Article |
Want to use this article elsewhere? Get Permissions
FPM E-Newsletter
Sign up to receive FPM's free, weekly e-newsletter, "Quick Tips & Insights."