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Podiatry Coding & Billing Alert

You Be the Coder:

Follow Initial Visit Guidelines for Shoring Up Your Documentation

Published on Tue Oct 27, 2015

Question: We often get patients with painful foot/ankle subluxation and sprains. Do we have any guidelines regarding the documentation requirements for an initial visit that help us prove the medical necessity? Pennsylvania Subscriber Answer: Definitely, yes. CMS requires appropriate documentation of patient’s initial visit examination proceedings. Starting from penning the patient’s history, which should include symptoms, relevant family history, past medical and [...]
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