documentation requirement

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    Does anyone have a CMS link to physician order requirements in the outpatient facility settings? (Think injection, infusions, etc). I am having a hard time presenting anything with specific details; i.e. written diagnosis. Thanks!
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    Question Required documentation for billable services - Nurse Visits

    Hello, I am looking for guidance on required documentation. Are SOAP notes and/or EHR master notes required for lab only or vaccine only visits (not with a provider)? Examples: Nurses Visit: Vaccine only, Nurses Visit: Covid vaccine only, Nurses Visit: Lab work (G0328, 82962, etc.) I appreciate...
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    Documentation Requirements for Labs

    I had a question regarding documentation requirements for independent laboratories. After talking with a lab they said they only have access to physician orders/ requisitions and the lab results. I know they say they just complete tests that are requested, but is that all they need? If they...
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    Question Documentation for Arthrocentesis and Injections

    I am trying to find a break down of the required elements of documenting arthrocentesis/injection. Clarification on what I am looking for to ensure the injection is documented correctly. Something I can use to show providers what is missing. I have the gist, but having a detailed break down...
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    Question Documentation Requirement for Assistant at C/S

    Hello! Our practice has two MD's and two CNM's. Often, the CNM's will assist during Cesarean Deliveries. The provider will list the assistant CNM in the heading of the operative report simply as: Assistant: CNM's name The remainder of the operative report does not mention the CNM again. I am in...