# 99213/99214 chart documentation



## bill2doc (Nov 19, 2013)

I must be crazy to ask this questions but I cannot find a templet document to show my provider what needs to be documented for either a 99213 or 99214 office visit.  I understand that there needs to be Hx, PE and MDM but is there not, in this world of technology overload, a templet that they can follow to ensure that they are documenting to support their level?  I'm looking for a templet that the doc can go down to ensure that they document each item such as CC, History (low, moderate, complex etc), PE (all those lovely bullet points), MDM (risk, data, Dx).  My doc does the work but I'm afraid he doesn't document it properly and I want to show him a templet for both the 99213/99214 to follow to ensure he is dictating everything he is doing during the visit.  We often tangle regarding history for a 99213 - he asks "really do I have to do a history for a patient that I see every month..... Does such documentation exist or am I crazy ?????

Thanks in advance


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## bill2doc (Nov 19, 2013)

Sorry Template... I sent before spell checking


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## mlbaker1974 (Dec 2, 2013)

*CMS evaluation and management services guide*

http://www.cms.gov/Outreach-and-Edu.../Downloads/eval_mgmt_serv_guide-ICN006764.pdf


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## bill2doc (Dec 5, 2013)

Thanks!


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