Wiki E/M template that can be carried over

[AmandaW]

Hello.

I'm trying to see if someone can help me with where I can find some guidelines as to what office visit componets can be carried over from the last visit as far as a 'template' goes without making it look like we just carried it over and "copied and pasted". Anyone know?? I would so appreciate your help!

 

[Walker22]

You can copy and paste elemnts from previous visits IF you make a note where and when they were copied from and that there were no changes.

 

[abishard]

Anything related to the review of systems and past family and social history may be referenced to include a date and location so long as any changes are noted.

This information is in CMS Documentation Guidelines.

As far as the exam, this cannot be carried over unless it was actually performed on that date of service.

 

[valleycoder]

yep, ROS and PFS history can be updated from previous visit as long as its documented that there are no changes from (previous date of service).