95 Help

- A -

Allergic/Immunologic

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED

	Introduction
	Documentation Of E/M Services
	Documentation Of History
	Documentation Of The Complexity Of Medical Decision Making

AND/OR MORTALITY

And/or Social History

Appropriateness

- B -

	Documentation Of Examination
	Documentation Of The Complexity Of Medical Decision Making

- C -

Cardiac electrophysiological

Catheterization

CHIEF COMPLAINT

	Documentation Of History
	Documentation Of The Complexity Of Medical Decision Making

Comorbidities/underlying

Components--history

Counseling

	General Principals of Medical Record Documentation
	Documentation Of History

- D -

	Documentation Of E/M Services
	Documentation Of History
	Documentation Of Examination
	Documentation Of The Complexity Of Medical Decision Making
	Counseling Or Coordination Of Care

Diagnostic endoscopies

Diagnostic Procedure

DOCUMENTATION GUIDELINES

	Welcome
	Introduction

DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE

DOCUMENTATION OF E/M SERVICES

DOCUMENTATION OF EXAMINATION

DOCUMENTATION OF HISTORY

DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

	Documentation Of E/M Services
	Documentation Of History

- E -

E/M

	Documentation Of E/M Services
	Documentation Of History
	Documentation Of Examination
	Documentation Of The Complexity Of Medical Decision Making
	Counseling Or Coordination Of Care

Echocardiography

	Documentation Of The Complexity Of Medical Decision Making
	Table Of Risk

Expanded Problem Focused

	Documentation Of History
	Documentation Of Examination

- F -

FAMILY AND/OR SOCIAL HISTORY

- G -

Gastrointestinal

	Documentation Of History
	Documentation Of Examination

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

- H -

Hematologic/Lymphatic

Hematologic/lymphatic/immunologic

High Complexity

History

HISTORY OF PRESENT ILLNESS

	Documentation Of E/M Services
	Documentation Of History

- I -

- K -

- L -

	Documentation Of E/M Services
	Documentation Of History
	Documentation Of Examination
	Documentation Of The Complexity Of Medical Decision Making
	Counseling Or Coordination Of Care

- M -

Management Options

MANAGEMENT SERVICES

Moderate Complexity

Musculoskeletal

	Documentation Of History
	Documentation Of Examination

- N -

	Documentation Of Examination
	Table Of Risk

Non-cardiovascular

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS

- O -

Over-the-counter

- P -

Physician/patient and/or

Present Illness

Presenting

Problem

Problem Focused

	Documentation Of History
	Documentation Of Examination

Problem Pertinent

Providing

- R -

Refer

Review

REVIEW OF SYSTEMS

RISK OF SIGNIFICANT COMPLICATIONS

ROS and/or

ROS and/or PFSH

- S -

	Documentation Of History
	Documentation Of Examination
	Documentation Of The Complexity Of Medical Decision Making
	Table Of Risk

Straightforward

Straight-forward

Systems

- T -

Type

- U -

- W -

WHAT DO PAYERS WANT AND WHY

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT