elements

  1. S

    Wiki Op Report Required Elements

    Hello there! Finally have time to get a little more in depth with the quality of all of our documentation. I am curious if anyone has any good resources to confirm CMS requirements for the components of an op report, specifically for colonoscopies. At this time we are watching out for the...
  2. A

    Wiki 1995 Exam Elements

    Hello, I've been auditing evaluation & management documentation for a long time and I've noticed something about the 1995 exam guidelines that I could really use some help on from a fellow auditor or coder or whomever can help! I get the overall guidelines are based off of body areas and/or...
    • archibequej3508
    • Thread
    • 1995 bullets elements exam guidelines
    • Replies: 2
    • Forum: E/M
  3. Rebecca Pate

    Wiki Help with HPI points for new patient

    I need some help with this one. "25 year old patient presents for initial visit. Husband is in the military and was transferred here 5/2017. She is here to establish care. She saw her GYN 2/2017 and IUD was still in place." This is all there is in the HPI. Everything else is fine, but I...
    • Rebecca Pate
    • Thread
    • elements history hpi
    • Replies: 4
    • Forum: E/M
  4. A

    Wiki Questions on AWV documentation

    Our practice is new to doing AWVs and I want to make sure we are documenting all the requirements appropriately. I've been reviewing the CMS document for AWVs: https://www.cms.gov/Outreach-and-Edu..._ICN905706.pdf, and I have a couple of questions. The required elements list ADLs and IADLs...
  5. A

    Wiki AWV Element Questions... need help please.

    Our practice is new to doing AWVs and I want to make sure we are documenting all the requirements appropriately. I've been reviewing the CMS document for AWVs: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf, and I have a...
  6. M

    Wiki Coding & ROS

    I have a question on whether you can use elements from ROS for your exam components? For example, the documentation has 12 elements in ROS and there are only 7 elements in the EXAM component - can you use elements from ROS in the EXAM component to get a comprehensive level? I was always taught...
  7. M

    Wiki Opinions on HPI please

    Hi I was wondering if anyone could tell me what elements they would pull from the following HPI. Pt has a history of bladder cancer, transitional cell, advanced initially treated with Gemzar, carbo, Taxol, and had surgery done and there was residual small cell component. She had four cycles...
    • MandyFlagg
    • Thread
    • e&m elements evaluation and management hpi hpi elements
    • Replies: 5
    • Forum: E/M
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