Physician Documentation

Browse our library of physician documentation tip sheets, training webinars, and informative articles about physician reimbursement, emergency medicine, and other acute care specialties. Or visit our Industry Events section to see the conferences we’re attending, including workshops we’re leading and topics we’re presenting on.

(Navigate our Resources by clicking the category links below)

Browse our library of physician documentation tip sheets for frequently-asked-questions and guidelines on a variety of topics, including: dictation formats, ICD-10, MIPS measures, critical care, medical decision making, and much more. Contact us to learn more about our onsite group training and on-demand chart reviews.

2018 MIPS Documentation Guidelines

Emergency Departments

Emergency Departments

Documentation requirements | #76 Central Venous Catheter ‐ Maximal Sterile Technique, MIPS Measure | #415: CT Use for Closed Head Injury | #91 Acute Otitis Externa Topical Treatment Only, #93 Acute Otitis Externa Oral Antibiotic Avoidance | MIPS Measure #317: Screening for Pre-Hypertension and Hypertension with Follow Up
Read More
Hospitalists

Hospitalists

Documentation requirements | #47 Advanced Care Plan | #130: Documentation of Current Medications in the Medical Record | #76 Central Venous Catheter ‐ Maximal Sterile Technique | #226 Smoking Cessation Intervention Performed
Read More
Urgent Care

Urgent Care

Documentation requirements for #47 Advanced Care Plan | #134 Depression Screening and Follow Up | #130: Documentation of Current Medications in the Medical Record | #76 Central Venous Catheter ‐ Maximal Sterile Technique | #226 Smoking Cessation Intervention Performed, Measure | #317: Screening for Pre-Hypertension and Hypertension with Follow Up
Read More

Physician Documentation Guidelines

Critical Care

Critical Care

When a patient receives aggressive management in the ED such as intubation, CPR, etc. it is NOT difficult to support critical care services. CPT clearly states what is included in critical care time such as reviewing test results or imaging studies, discussing the patients care with other healthcare providers and documenting in the patient’s medical record, most of which is provided away from the patient’s bedside.
Read More
Immobilization Care

Immobilization Care

Only bill for custom / molded splints with either of the following types of documentation in the note: Personal placement by the ED physician/MLP – OR – Placement by ancillary staff with a post-application check by the ED Physician/MLP.
Read More
Medical Necessity & Nature of Presenting Problem

Medical Necessity & Nature of Presenting Problem

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation is not the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.
Read More
Observation Care

Observation Care

Observation performed by the physician in the ED does not have to be rendered in an OBS unit and might not even be defined by what is billed by hospitals as observation care. Payment for physician observation care is close to what critical care pays, as much as 27-50% more than a level 5.
Read More
Procedural / Moderate Sedation

Procedural / Moderate Sedation

Moderate sedation is a time based code. Because the Moderate Sedation codes indicate a unit of time of 15 minutes, the ED chart must indicate 10 minutes or more of continuous intra-service (face-to-face) time to report Moderate Sedation. If the time threshold has not been met, then the code is not reportable.
Read More
Procedures

Procedures

Documentation tips for the following procedures: laceration repair, debridement, nail removal, incision and drainage, CPR, nasal epistaxis, foreign body removal, foreign body removal from the eye.
Read More
Psych Patient Disposition Decisions

Psych Patient Disposition Decisions

Psych patients awaiting the next step in their care present challenges for proper documentation and reporting of observation care. In this discussion we will consider the question of when physician observation care may be reported as the best reflection of the emergency physician’s evaluation and management service.
Read More
Scribes

Scribes

With the exception of obtaining PFSH and ROS, a scribe cannot act independently and may only document the practitioner's conversation and/or activities and relay information and cues back to the physician during the visit.
Read More
Supporting the Thought Process

Supporting the Thought Process

For E/M services, you are paid principally for your thought process. For good reason, Medicare calls E/M work “cognitive services” to distinguish it from “procedural services”. They recognize that thought process and the complexities of establishing a diagnosis have long been undervalued in the payment system.
Read More
Ultrasound (Diagnostic)

Ultrasound (Diagnostic)

US codes require “permanently recorded images” and “a final written report.” “Use of ultrasound without thorough evaluation of organ(s) or anatomic region, image documentation and final, written report, is not separately reportable.” (CPT)
Read More
Ultrasound (Procedural US)

Ultrasound (Procedural US)

If ultrasound guidance is used to complete a procedure it is generally appropriate to code for both the ultrasound guidance and the procedure performed. For example when performing an I&D of an abscess with ultrasound assistance, both the I&D 10061 and the ultrasound guidance for needle placement 76942-26 could be coded.
Read More
Wound Care

Wound Care

There are three levels of CPT code classification based on depth and complexity: Simple, Intermediate, Complex. And levels of repair can increase in complexity 3 ways.
Read More

Discover the clinical intelligence difference

Schedule a Free Practice Review