Physician

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D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. DG: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care. 16 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 113
1997 DOCUMENTATION GUIDELINES FOR EVALUATION & MANAGEMENT SERVICES TABLE OF CONTENTS Introduction ....................................................................................................…… 2 What Is Documentation and Why Is it Important?............................………. 2 What Do Payers Want and Why? .......................................................……… 2 General Principles of Medical Record Documentation ..................................... 3 Documentation of E/M Services........................................................................... 4 Documentation of History .................................................................................... 5 Chief Complaint (CC) ..................................................................................... 6 History of Present Illness (HPI) ..................................................................... 7 Review of Systems (ROS) .............................................................................. 8 Past, Family and/or Social History (PFSH) ................................................... 9 Documentation of Examination ........................................................................... 10 General Multi-System Examinations ............................................................ 11 Single Organ System Examinations ............................................................ 12 Content and Documentation Requirements ................................................ 13 General Multi-System Examination ………............................................... 13 Cardiovascular Examination ................................................................. 18 Ear, Nose and Throat Examination ....................................................... 20 Eye Examination .................................................................................... 23 Genitourinary Examination ................................................................... 25 Hematologic/Lymphatic/Immunologic Examination ........................... 29 Musculoskeletal Examination ............................................................... 31 Neurological Examination ..................................................................... 34 Psychiatric Examination ........................................................................ 37 Respiratory Examination ....................................................................... 39 Skin Examination ................................................................................... 41 Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 114
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Medicare Physician Guide A Resource
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ICD-9-CM Notice The International C
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MEDICARE PHYSICIAN FEE SCHEDULE ...
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CHAPTER ONE INTRODUCTION TO THE MED
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THE MEDICARE PROGRAM The Medicare P
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worker must have a specified number
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Part B - Medical Insurance Some of
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Where to Find Additional Informatio
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CMS contracts with one Quality Impr
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This chapter discusses Medicare pro
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staff or faculty appointments, part
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The following forms are often requi
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Accept the Medicare allowed amount
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Below is an illustration of the pay
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cultural background, or ability to
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This chapter provides information a
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suppliers can obtain a list of elec
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Insurer information (name, group nu
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Coordination of Benefits Contractor
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In these situations, the physician
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Where to Find Additional Informatio
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OTHER HEALTH INSURANCE PLANS Medica
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Part B Railroad Retirement Benefits
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This chapter discusses Medicare cov
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2) Renal dialysis treatments Renal
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2) Furnished by the physician or au
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Services that are considered not me
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This chapter discusses common sets
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International Classification of Dis
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CHAPTER SIX PROTECTING THE MEDICARE
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codes that describe what is and is
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Page 127 and 128: Problem Focused Examination - shoul
Page 129 and 130: System/Body Area Respiratory Elemen
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Page 149 and 150: Neurological Examination System/Bod
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Page 157 and 158: System/Body Area Skin Elements of E
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