Elizabethchris
Networker
In reference to "required elements" below, is that the 3 KEY components (History, exam, and MDM)? Or just the history and exam?
For established patient office/outpatient visits, when relevant information is already contained in the medical record, providers may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary
For established patient office/outpatient visits, when relevant information is already contained in the medical record, providers may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary