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
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Coding Pre-Ops Template

A template showing the requirements for coding different levels of pre-operative visits
Tool as published
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CPT E/M Office Revisions Level of Medical Decision Making

The official medical decision making table from the American Medical Association
Tool as published
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Decision Tree for New and Established Patients

A decision tree for determining whether a patient is new or established
Download Format: PDF
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DME Documentation Templates

Templates for documenting medical necessity of certain types of durable medical equipment
Download Format: PDF
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DME Ordering Templates

Templates for ordering certain types of durable medical equipment
Download Format: PDF
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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
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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
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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
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FPM Superbill

A superbill to capture the codes most common in office-based outpatient practice
Download Format: Excel
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Home and domiciliary E/M codes and payment rates

A list of CPT codes for billing home visits
Tool as published
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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
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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
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Medicare Superbill

A superbill to capture the CPT and HCPCS codes most commonly used in office visits with Medicare patients
Download Format: Excel
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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
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Nursing Home Documentation Form

A one-page form that standardizes and simplifies clinician documentation of nursing home care
Download Format: PDF
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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
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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
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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
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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
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