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 |
Coding Pre-Ops Template |
| A template showing the requirements for coding different levels of pre-operative visits |
| Tool as published |
| 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 |
E/M Code Frequency Report |
| A spreadsheet that enables physicians to easily compare their office visit coding patterns with one another and with national benchmarks |
| Download Format: Excel |
| Source Article |
E/M Visit Encounter Form |
| A encounter form for E/M visits that includes a checklist to facilitate counting history and exam elements for accurate coding selection |
| 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 |
Home and domiciliary E/M codes and payment rates |
| A list of CPT codes for billing home visits |
| Tool as published |
| 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 |
Medicare Wellness Visits IPPE and AWV |
| A table outlining Medicare requirements for the initial preventive physical exam, the initial annual wellness visit, and the subsequent annual wellness visit |
| Download Format: PDF |
| 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 |
Office Visit Tornado Template |
| A table showing medical decision making data and risk plus total time thresholds to help you quickly determine the level of E/M office visits |
| Tool as published |
| Source Article |
Prolonged Services Guide |
| A table outlining the codes Medicare and other payers require for reporting prolonged services |
| Tool as published |
| Source Article |
Screening and Assessment Coding Reference |
| Descriptions of each code and examples of standardized instruments that may be used for screening and assessment services |
| 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 |
Total Time Plus Prolonged Services Template |
| A table outlining the total time thresholds for each E/M visit level as well as prolonged services |
| Tool as published |
| Source Article |
What Level of Problem Did I Address? |
| A table for identifying the types of problems associated with different levels of E/M office visits |
| Tool as published |
| Source Article |
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