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I am attempting to locate a good example of a well documented comprehensive eval and management note to use as a teaching tool for one of the urologists in my group practice, who insists that because of his specialty, he is not necessarily required to present his documentation in the same format as, perhaps, a general practice doc or family practitioner. This is a doc who requires documentationto substantiate every recommendation we make. Any ideas where i could fins some good examples of documentation? This will probably help to persuade the other specialists in my group as well. They have not been receiving good feedback with their in house audit results, so I am trying to take a new approach that might work more effectively. :eek: Thanks

Does your doc dictate his office visits or are you using a template that he/she fills in?

The documentation doesnt necessarily have to be in a specific format (however I do recommend the traditional History, Exam, Assessment & Plan format) as long as all the required information is documented.

Medicare unfortunately doesnt offer different sets of guidelines for different specialties. So it doesnt matter what kind of doctor you are the requirements for E/M codes are the same, depending on which guidelines you use 95 or 97.
1997 Genitourinary Specialty Exam

Print out the 1997 guidelines for the Genitourinary Specialty Exam. This clearly outlines what the need to cover in their documentation to meet the exam guidelines for their specialty.

Hope that helps.

F Tessa Bartels, CPC, CEMC

Well, I have a meeting set up with him/them today, so I guess I will soon learn if it will help. Thanks for your assistance!