FPM Toolbox

Coding and Documentation

Download tools to help you understand coding and documentation requirements for new and established patient visits.

Chart Review Form

A form used to evaluate progress notes to determine whether the documentation supports the coding
Download Format: PDF
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Decision Tree for New and Established Patients

A decision tree for determining whether a patient is new or established
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Documentation Requirements for Established Patient Office Visits

A table that shows the history, exam and medical decision making requirements for each of the established patient office visit codes
Download Format: PDF
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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
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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.
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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.
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Evaluation and Management Guidelines at a Glance

A two-page summary of the documentation guidelines for E/M services
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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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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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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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Preventive Services Covered by Medicare in 2018

A list of Medicare preventive service codes and coverage requirements
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