I would quote directly from the documentation guidelines. In addition, I would cut and paste what ancilliary staff may document per the DG's, which is the Review of Systems (ROS), and Past, Family, and Social hx (PFSH). Here is the link to the '95 DG: http://www.cms.hhs.gov/MLNProducts/Downloads/1995dg.pdf
Please refer to Page 5.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join